Fundamentals of Nursing Q 321
Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?
A. Assessing the client to rule out possible complications secondary to surgery.
B. Checking the client's chart to determine when pain medication was last administered.
C. Explaining to the client that the pain should not be this severe 3 days postoperatively.
D. Obtaining an order for a stronger pain medication because the client's pain has increased.
Correct Answer: A. Assessing the client to rule out possible complications secondary to surgery.
The nurse’s immediate action should be to assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence. The nurse should never administer pain medication without assessing the client first.
Option B: Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may be more a reflection of other methods the patient is using to cope with the pain rather than pain relief itself.
Option C: Pain is subjective, and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.
Option D: Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. The World Health Organization (WHO) in 1986 published guidelines in the logical usage of analgesics to treat cancer using a three-step ladder approach – also known as the analgesic ladder. The analgesic ladder focuses on aligning the proper analgesics with the intensity of pain.