Association between Vital Signs Fluctuations and Pain Severity among Critically-ill Patients

ABSTRACT


INTRODUCTION
The sensation and perception of pain are important for human life and have multidimensional and personal experiences in confronting various stimuli that may produce tissue damage (Alnajar et al., 2021). People who are able to verbalize their pain can be easier to assess accurately, because they are able to depict the pain that they feel (Oliveira et al, .2019). Therefore, the first step for effective pain management is diagnosing the presence and severity of pain among critically-ill patients using valid and reliable scales for the pain assessment. Therefore, health care providers (HCPs) should use an appropriate tool to assess pain (Deldar et al., 2018).
Pain is normally unpleasant and undesired; however, it also provides a defensive function, warning the body of potentially harmful circumstances (AL Attar, 2014;Terkawi, 2017). As a result, pain is considered the fifth vital sign, and it is recommended that pain to be assessed together with all other vital signs (Valério et al., 2019). Most patients in the ICU are not able to make any self-report pain due to their deteriorating health condition(s), such as, intubation and sedation. Alternately, patient's behaviors have proved to be a reliable way of communicating. Indicators of pain in intensive care are a key component of a nurse's assessment competence (Na'el & Mohammed, 2019;AL-Fayyadh, 2018;Kadhim, 2014). Routine pain assessment, as an attached step with vital signs in the critical care setting, is associated with a reduced duration of mechanical ventilation, a lower risk of infection, decreased use of sedative agents, and a reduced ICU stay (Yamashita et al., 2017;AL-Saad & AI-Jaafari, 2018). Patients hospitalized in ICUs may frequently experience both short-and long-term physiological and psychological issues, such as hemodynamic instability, high blood sugar, infections, delirium, anxiety, prolonged hospitalization, increased medical costs, and most importantly, potential neuropathic pain and chronic pain (Kia et al., 2021). Patients in the medical, surgical, and trauma departments of the ICUs are suffering from pain both at rest and while receiving standard ICU management (Liu, 2021).
Patient's physiological reactions would also be added to the pain assessment data. The sympathetic nervous system is triggered during acute pain, triggering a multitude of physiological reactions such as elevated blood pressure, pulse rate, pallor, respiratory rate, excessive sweating, and pupil size dilation (Shaikh et al., 2018). In medical, surgical, and trauma patients who were unable to describe their pain, the Behavioral Pain Scale (BPS) was approved to be the most reliable and valid pain evaluation instrument. The BPS can be used for sedated patients and depends on the three behavioral categories, including facial expression, upper-limb movements, and mechanical ventilation compliance (Salvadore, 2018;Berman & Snyder, 2018). The lack of evidence regarding pain assessment and lack of collaboration between physicians and nurses were identified as barriers to effective pain assessment and management. In addition, the physical and cognitive impairments of many critically ill patients and communication impediments, such as intubation, and diminished level of consciousness, are factors that shouldnot be overlooked when practicing pain management (Arrar & Mohammed, 2020;Gélinas & Arbour, 2009).
The main study question was: is there a relationship between pain severity and vital signs fluctuations?.

AIMS OF THE STUDY
The Aim of study was to describe vital signs and pain severity among critically ill patients. As well to find the relationship between pain severity and a patient's vital signs. Finally to compare the vital signs at rest, during routine nursing and post-routine nursing procedures within 20 minutes.

METHODOLOGY:
Study design: Descriptive-correlational design study. This research method supported the study's primary goal. While previous studies were conducted to assess the pain level and use different methods, the knowledge gained from these previous studies provides unclear answers. This descriptive correlational study can provide additional insight into this phenomenon. There are four types of schools in Erbil city according to the teaching language of that school (Kurdish, Arabic, Turkish or English). The 1st three types are either male or female schools, while the English schools are mixed. The teaching language of the majority of the schools (68 out of 78) is Kurdish.

Ethical Considerations and Official Agreements:
With the submission of the study protocol, ethical approval was sought from the Scientific Committee of the Nursing Faculty, University of Baghdad. The reference number is 34, dated 5/12/2021. The researcher submitted a detailed description of the study, including problem statement, objectives, and questionnaire, to the Ministry of Planning (Central Statistical Organization) and to the Medical City Directorate, and Al-Muthanah Health Directorate, in order to obtain official permission to carry out the study. Informed consent was obtained from the patient's kin due to the selected patients' being unable to communicate. From the hospital administration, informed consent was also obtained to use the patient's medical file. To verify that the rights, welfare, and well-being of human participants are completely protected while they are participating in a study; the researcher has completed the Human Research Protection Fundamental Training offered by the Office for Human Research Protection. Study Instrument: The Behavioral Pain Scale (BPS) was used in this study after obtaining official permission from the primary author Dr. Jean F Payen. The BPS is both reliable and valid for use in assessing pain for mechanically ventilated-sedated patients who are hospitalized in the ICUs and the patients who are unable to communicate and expressing their distress. Cronbach's alpha coefficients of the scale was highly reliable; the reliability coefficient for the BPS was 0.79 (Payen, 2001;Salvadore, 2018). The BPS contain three main domain Facial expression, compliance with mechanical ventilation and upper limb movement. Within each domain, behavioral responses are scored from (1) that indicate no pain to (4), which is the worst score that indicates the presence of pain. The health care professional uses BPS to assess the presence and severity of the pain and decide what the best behavioral response will be within each domain. Patients' responses are to be scored from 1 to 4 in each domain, with a total score of 12 that indicates maximum pain (Payen et al., 2001). Data Collection Method: The data was collected through observational methods from January 18th , 2022, to April 7th , 2022. The severity of pain were measured objectively through observation of the patient's behavioral response using BPS and vital signs measured from patient's monitoring machine. The study sample include 135 patients selected purposively to find the relationship between vital signs readings and pain severity among critically ill patients with a diminished level of consciousness. The pain and vital signs were determined through three phases: the first was assessing patients' pain during rest (without any invasive or therapeutic procedures); the second was during routine nursing procedures. Finally, the third phase, which was done to determine patient's pain within 20 minutes post-nursing procedures. SpO2 levels were also assessed during all three assessment phases. According to Honan et al., (2019) the mean arterial pressure, was measured and categorized according to the following formula: (MAP= [2 × diastolic+ systolic]/3). And classification of mean arterial pressure was calculated according to Kundu et al., (2017). Settings: The study was conducted by using observational methods, targeting hospitalized adult patients in the ICUs in Baghdad teaching hospitals; Martyr Ghazy Al-Hariri Hospital for Surgical Specialties; and the Private Nursing Home Hospital of the Medical City Directorate; Al-Hussein Teaching Hospital of Al-Muthanna Health Department. Participants and Study Design: The purposive nonprobability sampling method was used for the current study method which is selected depending on population characteristics, eligibility criteria and the study's aims. The exclusion criteria of this study included patients who were < 18 years old. Patients who have had neuropathic conditions such as Myasthenia Gravis and Guillain-Barre Syndrome (GBS), patients with upper limb neuropathy were excluded because these conditions may interfere with behavioral responsivity when using the BPS. Patients who can report pain were excluded because the research tool was designed for patients who are unable to report the presence and intensity of pain, as well as patients with upper limb fractures. Those on a heavy anesthetic regimen were also excluded because they may be unable to show any behavioral response which may interfere with the research tool usability and measurement accuracy. The Sample consisted of 135 patients the sample size was calculated according to A-priori sample sizes for student t-tests. -Limitations: The main limitations of the study were the relatively small sample size and the timeframe for the study and data collection. The more relevant method to classify the patient's consciousness and sedation level in the ICUs is the Richmond Agitation Sedation Scale (RASS), which is not used in the current study since it is not applicable in the health care settings and the health care providers and the informed consent to use the RASS was not obtained from the primary author. Therefore, the patients were classified according to the Glasgow coma scale. 100.0 The underlined numbers in table 1 represent the highest percentages of the selected variables. The dominant percentage of gender distribution for the targeted sample was males, representing more the half (58.5%) of the study sample and the age groups included (18-< 32 years old), more than one quarter with percentage (28.9 %).  (2) represent the highest percentages of the selected variables. In which the majority of the collected samples were as follow: patient's length of staying days, more than half (55.6%) of the subjects were hospitalized for 3 to 5 days. Additionally, more than half (61.5%) of the participants were medically classified as non-traumatic patients. Moreover, the consciousness level for the patients according to GCS was (5-8), representing more than half (58.5%) of the study subjects. Finally, narcotics was approximately used by about two-fifths (42.2%) of study subject.

Table (3):
Descriptive statistics of overall vital signs and SpO2 level during all three phases of assessment (preroutine nursing procedures, during-and within 20 minutes post-routine nursing procedures. The underlined numbers in table (3) represent the highest percentages of the selected variables. As noticed, the vital signs and pain severity increased during routine nursing care procedures and, conversely, the SpO2 decreased below normal during the procedural phase compared to pre and post-nursing procedures. Finally, the overall pain intensity was presented, which showed that more than two thirds of patients (71.1%) had an unacceptable pain level.

Pre-routine nursing procedures
During-routine nursing procedures

Post-routine nursing procedures
Pain severity   Table 4 shows there is a statistically significant association between the overall pain score and overall vital signs pre-nursing procedures, during nursing procedures and post nursing procedures. When the pain intensity increases, the respiratory rate, heart rate, and mean arterial pressure also increase, so there is a positive relationship between these variables. Conversely, it shows there is no statistically significant association between overall pain score and SpO2% level during all three phases. Repeated measurement ANOVA test in Table 5 shows that there is a statistically significant difference between the overall vital signs during all three measurement phases. While the body temperature shows that there is no statistically significant difference between the body temperatures during three measurement phases. Ultimately, the SpO2% saturation level shows that there is a statistically significant difference between the SpO2% level during three measurement phases of pre-during and post nursing procedures within 20 minutes.

Figure (1): Vital signs and SPo2 during all three phases
The mean plot show Difference between all three phases pre-during and post routine nursing care procedures of vital signs and SpO2 levels. With a significant elevation during routine nursing procedures except the SpO2 level which is relatively below normal during routine nursing procedures phase.

DISCUSSION
The findings in table (4-2) showed that more than one quarter (28.9%) of the study participants' age group was (18-<32 years old). This result is similar to a cross-sectional study carried by (Alikiaie et al., 2019). Regarding the patients' gender, findings of the study indicated that more than half (58.5%) of the study sample were males. These results were not surprising to the researcher because male patients are more risky to develop cerebrovascular accidents and road traffic accidents due to these condition most common hodpitalized in the ICUs. This result was confirmed by an observational study Kemp et al., (2017), which indicated that the highest percentage  (Ayasrah et al., 2014). This may be due to the fact that male individuals are more at risk of the occurrence of cerebrovascular accidents according to Hinksman et al., (2022), Analogaili & Khullof, (2021, which indicate that male individuals are more susceptible to road traffic accidents than females. The findings in table 2 revealed more than half (61.5%) of the participants were medically classified as non-traumatic patients. This was confirmed by the researchers Oliveira et al., (2019). The majority (58.5%) of the patient's consciousness level was (5-8), according to the Glasgow coma scale. These results were not surprising to the researcher since the patients were hospitalized in intensive care units. This was validated in a descriptive-correlational retrospective study (Morris et al., 2021).
Moreover, the pain medication classification, the results appeared in this way: the majority of the patients' were under mild regimen of narcotics medications was approximately used by about twofifths (42.2%) of the study subjects. This result was not surprising to the researchers since the patients are hospitalized in ICU, frequently treated with mild, moderate, and even heavy sedative regimens (Payen et al., 2001). The study results are supported by a prospective cohort study of (klein et al., 2018).
Non-parametric Spearman Correlation in the Table 4 shows there is a statistically significant association between the overall pain score and overall vital signs readings: pre-nursing procedures, during nursing procedures and post nursing procedures. Because the rate of breathing, the heart rate, and the mean arterial pressure, all go up in tandem with an increase in the intensity of the pain, it can be say that there is a positive relationship between these variables. This result did not surprise the researcher since alteration in the vital signs was expected as a reaction to increased patients' pain and discomfort and this was supported by the Sutari et al., (2014).
Repeated measurement ANOVA test in Table  5 shows that there is a statistically significant difference between the overall vital signs during all three measurement phases. This result was confirmed by Arbour et al., )2014); by Erden et al., (2018), a repeated measure study design. They discovered a significant difference in vital signs during routine care procedures versus pre-and postprocedures. These results were not surprising to the researchers as last mentioned the change or alteration in vital signs was an expected outcome as a response to patients' discomfort and suffering. This was confirmed by (Considine et al., 2020;Ayasrah, 2019). It is crucial to comprehend how unbalanced key physiological signals affect patients' hemodynamics since pain is a significant indicator of pain and instability. Therefore, when utilizing traditional vital signs to provide support to patients in pain, physiological and biochemical processes stand out as the most essential to monitor and document in order to simultaneously explore pain symptoms (Araujo & Romero, 2015). While the body temperature shows that there is no statistically significant difference between the body temperatures during three measurement phases. This result was confirmed by Khojeh et al., (2018). Ultimately, the SpO2% saturation level shows that there is a statistically significant difference between the SpO2% level during three measurement phases of pre-during and post nursing procedures within 20 minutes. That was an expected outcome of increased pain episodes and was confirmed by a descriptive observational study of Menekli et al., (2021).

CONCLUSION
The pain severity had reached its highest level during nursing procedures, as it showed a severe unacceptable pain score, which is both clinically and ethically unacceptable. And there was a significant statistical difference was authenticated in vital signs during nursing procedures and within 20 minutes compared to pre-nursing procedures. Therefore, the nurses should be alert to any change in patients' health status and vital signs and attempt to reduce patients' discomfort that leads to disturbance of their health conditions. Aiming for minimizing patients' pain and discomfort that may lead to disturbance of patient's condition. There was a significant statistical difference, which was authenticated, between Spo2% levels, pre-nursing procedures, during nursing procedures, and within 20 minutes post-nursing procedures. Therefore, the nurses should be alert to any change in patients' health status and vital signs and attempt to reduce patients' discomfort that leads to disturbance of their health conditions.

NURSING IMPLICATIONS
It is important to use the EBP when providing intensive care unit patients' care and during routine nursing care provision. It can improve patient's outcomes. Also frequently assessing and monitoring patients' discomfort and pain intensity through the use of recommended tools for assessing pain, particularly for non-communicative critically ill patients, through the use of the behavioral pain scale and other tools that are designed for patients unable to report pain can be reduce the needs for mechanical ventilation and reduce patients length of stay in the ICU.

RECOMMENDATIONS
It is recommended to depend the changes in vital readings because it is considered important indicator of pain presence and its severity among patients who are unable to express their pain in the intensive care units. It is highly recommended that Intensive Care Units use up-to-date clinical protocols to measure pain. Of equal importance, mandatory practice policies of using of the well-established behavioral pain assessment tools, particularly in Iraqi ICUs, are crucial. It is becoming mandatory to maximize the level of care quality to improve patients' recovery. Using behavioral pain assessment tools such as the Behavioral Pain Scale that depend on behavioral response for non-communicative patients are extremely required especially when supported with vital signs fluctuations assessment.