5The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client’s pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply.
increased blood pressure and heart rate as shown on the cardiac monitor
Numbers 1, 2, 3, 4, and 6 are correct.
Grabbing at the bed rails and general restlessness may indicate pain. Biting the ventilator tubing and breathing over the vent due to increased respiratory rate are other indicators of pain. Facial grimacing and frowning is another pain indicator. Guarding an area of the body during the “sedation vacation” or stiffness or rigidity can indicate a pain response. Blood pressure and heart rate generally increase when experiencing pain. Decreased urinary output is not an indicator of pain. Based on the client’s injury, disease process, or surgical procedures, the nurse should be able to anticipate what type and intensity of pain the client may experience. When multiple indicators suggest pain, the nurse should administer pain medications as ordered. It is important to remember that just because a client is sedated does not mean he is not experiencing pain.
