Fundamentals of Nursing Q 303
Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement? Select all that apply.
A. Assessing the client's bowel sounds.
B. Taking the client's blood pressure and apical pulse.
C. Obtaining a pulse oximeter reading.
D. Notifying the health care provider.
E. Determining the last time the client received pain medication.
F. Encouraging the client to turn, cough, and deep breathe.
Correct Answers: A, B, & E
The nurse must rule out complications prior to administering pain medication, so her interventions would include assessing to make sure the client has bowel sounds and determining if the client is hemorrhaging by checking the client’s blood pressure and pulse. The nurse must also make sure the pain medication is due according to the health care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain.
Option A: Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.
Option B: Pain should be screened every time vital signs are evaluated. Many health facilities set pain assessment as the “fifth vital sign” and should be added to during routine vital signs assessment.
Option C: Investigate signs and symptoms related to pain. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain. In some instances, the existence of pain is disregarded by the patient.
Option D: There is no need to notify the health care provider in this situation. Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.
Option E: Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., use of analgesics). A combination of both therapies may be more effective and the nurse has the duty to inform the patient of the different methods to manage pain.
Option F: Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, deep breathing.