Description of behaviors in nonverbal critically ill patients with a traumatic brain injury when exposed to common procedures in the intensive care unit: a pilot study.

Behavioral indicators are strongly recommended for pain assessment in nonverbal patients. Although pain-related behaviors have been studied in critically ill patients, those with a traumatic brain injury (TBI) have been either excluded or underrepresented. Because these patients also likely experience pain, research is urgently needed to generate knowledge in this field. This pilot study aimed to explore pain-related behaviors of critically ill TBI patients when exposed to common procedures in the intensive care unit (ICU), using video recording at the bedside and a newly developed coding system. Ten TBI patients hospitalized in the ICU participated. A 44-item behavioral checklist created from existing tools was used as a coding system to identify behaviors before, during, and 20 minutes after a nociceptive procedure (turning) and a nonnociceptive procedure (noninvasive blood pressure [NIBP]). Patients were video recorded to check for interrater agreement between two trained observers. TBI patients exhibited more behaviors during turning than at rest or during NIBP (p < .001). The following behaviors were observed during turning: levator contraction (n = 7), frowning (n = 5), opening eyes (n = 5), weeping eyes (n = 5), raising eyebrows (n = 5), activating the ventilator alarms (n = 7), and muscle tension (n = 5). No change in behaviors was noted during NIBP. After educational training and using videos, the average percentage of agreement for observed behaviors between two trained research assistants was 96%. Pain in critically ill TBI patients can be detrimental to health and recovery. ICU clinicians should be aware of pain-related behaviors to enable better detection and treatment in this highly vulnerable group.