Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 68 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute
Which of the following statements reflect an accurate understanding of the patient's current pain experience by the nurse? 1. The vital signs are normal; the patient is not experiencing pain.
2. The vital signs reflect a sympathetic nervous system response to pain.
3. Further assessment to determine the presence of pain is indicated.
4. Mechanically ventilated patients are not alert enough to experience pain.
3
Rationale: The nurse must complete additional assessments to determine if the patient is experiencing pain. Parasympathetic nervous system influences on vital signs can cause vital signs to be within normal limits in the presence of pain. The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain. Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting.
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