Issues in administration| Volume 37, ISSUE 6, P466-475, November 2008

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Critical care nurses provide their perspectives of patients' symptoms in intensive care units

Published:September 22, 2008DOI:


      Patients in intensive care units (ICUs) can be adversely affected by distressing symptoms. When critically ill patients are unable to self-report symptoms, ICU nurses become proxy reporters.


      The purpose of this prospective, descriptive study was to explore how ICU nurses assess and treat distressing symptoms in critically ill patients at high risk of dying.


      Twenty-two nurses participated in this single-site, prospective, descriptive study and described their patients' symptoms and how the symptoms were being managed in response to interviews that used open-ended questions. Taped interviews were transcribed verbatim, and themes were identified.


      Three major themes were derived from the data: 1) signs of symptoms, (2) treatment of symptoms, and (3) “symptoms” versus “signs.” Most nurses did not make distinctions between the assessment of “signs” of disease and the assessment of “symptoms,” and consequently, signs and symptoms were frequently inventoried collectively.


      Critically ill patients experience a broad range of symptoms. Continued attempts to validate nonverbal measures of symptoms are warranted because lack of such measures may adversely affect symptom treatment for critically ill patients. Furthermore, heightened awareness and increased education of nurses to differentiate between signs and symptoms lay the foundation for increasing attention on symptoms, improving accuracy of symptom assessment, and guiding appropriate symptom management.
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        • Dodd M.
        • Janson S.
        • Facione N.
        • et al.
        Advancing the science of symptom management.
        J Adv Nurs. 2001; 33: 668-676
        • Desbiens N.A.
        • Wu A.W.
        • Broste S.K.
        • et al.
        Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations.
        Crit Care Med. 1996; 24: 1953-1961
        • Desbiens N.A.
        • Mueller-Rizner N.
        • Connors A.F.
        • Wenger N.S.
        • Lynn J.
        The symptom burden of seriously ill hospitalized patients.
        J Pain Symptom Manage. 1998; 17: 248-255
        • Kaye P.
        Symptom control in hospice and palliative care.
        Hospice Education Institute, Connecticut1990
        • Lo B.
        Improving care near the end of life: why is it so hard?.
        JAMA. 1995; 274: 1634-1636
        • Lynn J.
        • Teno J.M.
        • Phillips R.S.
        • et al.
        Perceptions by family members of the dying experience of older and seriously ill patients.
        Ann Intern Med. 1997; 126: 97-106
        • Nelson J.E.
        • Meier D.
        • Oei E.J.
        • et al.
        Self-report symptom experience of critically ill cancer patients receiving intensive care.
        Crit Care Med. 2001; 29: 227-282
        • Sheehan D.C.
        • Forman W.B.
        Symptomatic management of the older person with cancer.
        Clin Geriatr Med. 1997; 13: 203-219
        • SUPPORT Principal Investigators
        A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT).
        JAMA. 1995; 274: 1591-1598
        • Kutner J.S.
        • Bryant L.L.
        • Beaty B.L.
        • Fairclough D.L.
        Symptom distress and quality-of-life assessment at the end of life: the role of proxy response.
        J Pain Symptom Manage. 2006; 32: 300-310
        • Pickard A.S.
        • Knight S.J.
        Proxy evaluation of health-related quality of life: a conceptual framework for understanding multiple proxy perspectives.
        Med Care. 2005; 43: 493-499
        • Pisani M.A.
        • Inouye S.K.
        • McNicoll L.
        • Redlich C.A.
        Screening for preexisting cognitive impairment in older intensive care unit patients: use of proxy assessment.
        J Am Geriatr Soc. 2003; 51: 689-693
        • Teske K.
        • Daut R.L.
        • Cleeland C.S.
        Relationships between nurses' observations and patients' self-reports of pain.
        Pain. 1983; 16: 289-296
        • Stephenson N.N.
        A comparison of nurse and patient perceptions of postsurgical pain.
        J Intraven Nurs. 1994; 17: 235-239
        • Klopfenstein C.E.
        • Herrmann F.R.
        • Mamie C.
        • Van Gessel E.
        • Forster A.
        Pain intensity and pain relief after surgery.
        ACTA Anaesthesiol Scand. 2000; 44: 58-62
        • Grossman S.A.
        • Sheidler V.R.
        • Swedeen K.
        • Mucenski J.
        • Piantadosi S.
        Correlation of patient and caregiver ratings of cancer pain.
        J Pain Symptom Manage. 1991; 6: 53-57
        • Everett J.J.
        • Patterson D.R.
        • Marvin J.A.
        • Montgomery B.
        • Ordonez N.
        • Campbell K.
        Pain assessment from patients with burns and their nurses.
        J Burn Care Rehabil. 1994; 15: 194-198
        • Puntillo K.
        • Neighbor M.
        • O'Neil N.
        • Nixon R.
        Accuracy of emergency nurses in assessment of patients' pain.
        Pain Manag Nurs. 2003; 4: 171-175
        • Harrison A.
        Comparing nurses' and patients' pain evaluations: a study of hospitalized patients in Kuwait.
        Soc Sci Med. 1993; 36: 683-692
        • Van der Does A.J.
        Patients' and nurses' ratings of pain and anxiety during burn wound care.
        Pain. 1989; 39: 95-101
        • Choiniere M.
        • Melzack R.
        • Girard N.
        • Rondeau J.
        • Paquin M.J.
        Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries.
        Pain. 1990; 40: 143-152
        • Nekolaichuk C.L.
        • Bruera E.
        • Spachynski K.
        • MacEachern T.
        A comparison of patient and proxy symptom assessment in advanced cancer patients.
        Palliative Med. 1999; 13: 311-323
        • Guru V.
        • Dubinsky I.
        The patient vs. caregiver perception of acute pain in the emergency department.
        J Emerg Med. 2000; 18: 7-12
        • Nelson J.E.
        • Meier D.
        • Litke A.
        • Natale D.A.
        • Siegel R.E.
        • Morrison R.S.
        The symptom burden of chronic critical illness.
        Crit Care Med. 2004; 32: 1527-1534
        • Li D.
        • Puntillo K.
        A pilot study of co-existing symptoms in intensive care patients.
        Adv Nurs Res. 2006; 19: 216-219
        • Horton R.
        Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting.
        Palliative Med. 2002; 16: 488-494
        • Dowdy M.D.
        • Robertson C.
        • Bander J.A.
        A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay.
        Crit Care Med. 1998; 26: 252-259
        • Portenoy R.K.
        • Thaler H.T.
        • Kornblith A.B.
        • et al.
        The memorial symptom assessment scale: an instrument for the evaluation of symptom prevalence, characteristics and distress.
        Eur J Cancer. 1994; 30A: 1326-1336
        • Chang V.J.
        • Hwang S.S.
        • Feuerman M.
        • Kasimis B.S.
        Symptom and quality of life survey of medical oncology patients at a Veterans Affairs Medical Center.
        Am Cancer Soc. 2000; : 1175-1183
        • Kutner J.S.
        • Kassner C.T.
        • Nowels D.E.
        Symptom burden at the end-of-life: Hospice providers' perceptions.
        J Pain Symptom Mgmt. 2001; 21: 473-480
        • Chang V.J.
        • Hwang S.S.
        • Feuerman M.
        • Kasimis B.S.
        • Thaler H.T.
        The memorial symptom assessment scale short form (MSAS-SF).
        Am Cancer Soc. 2000; : 1162-1171
        • Guo H.
        • Fine P.G.
        • Mendoza T.R.
        • Cleeland C.S.
        A preliminary study of the utility of the brief hospice inventory.
        J Pain Symptom Mgmt. 2001; 22: 637-648
        • Sandelowski M.
        Whatever happened to qualitative description?.
        Res Nurs Health. 2000; 23: 334-340
        • Murphy M.R.
        • Escamilla M.I.
        • Blackwell P.H.
        • et al.
        Assessment of caregivers' willingness to participate in an intervention research study.
        Res Nurs Health. 2007; 30: 347-355
        • Kwekkeboom K.L.
        • Herr K.
        Assessment of pain in the critically ill.
        Crit Care Nurs Clin North Am. 2001; 13: 181-194
        • Harver A.
        • Mahler D.A.
        The symptom of dyspnea.
        in: Dam M. Dyspnea. Futura, New York1990: 1-53
        • Gelinas C.
        • Fillion L.
        • Puntillo K.
        • Viens C.
        • Fortier M.
        Validation of a pain observation tool (POT) in critically ill adult patients.
        Am J Crit Care. 2006; 15: 420-427
        • Stannard D.
        • Puntillo K.
        • Miaskowski C.
        • Gleeson S.
        • Kehrle K.
        • Nye P.
        Clinical judgment and management of postoperative pain in critical care patients.
        Am J Crit Care. 1996; 5: 433-441
        • Almerud S.
        • Petersson K.
        Music therapy—a complementary treatment for mechanically ventilated intensive care patients.
        Intensive Crit Care Nurs. 2003; 19: 21-30
        • Tracy M.F.
        • Lindquist R.
        • Watanuki S.
        • et al.
        Nurse attitudes towards the use of complementary and alternative therapies in critical care.
        Heart Lung. 2003; 32: 197-209
        • Stillwell S.B.
        Mosby's critical care nursing reference.
        3rd ed. CV Mosby, Missouri2002
        • Bick R.L.
        Disseminated intravascular coagulation current concepts of etiology, pathophysiology, diagnosis, and treatment.
        Hematol Oncol Clin North Am. 2003; 17: 149-176