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Chapter 30: Pain Assessment

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Chapter 30: Pain Assessment

6 problems · 0 figures

Case Study 30.4.1 §30.4 source ↗

Refer back to Chapter 19 Oxygenation and Perfusion, Chapter 22 Activity, Chapter 24 Skin Integrity, and Chapter 26 Urinary Elimination for Unfolding Case Study Parts 1 to 7 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Flow Chart 1730: Assessment
Blood pressure: 132/80 mm Hg
Heart rate: 94 beats/minute
Respiratory rate: 18 breaths/min
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 94 percent on room air
Pain: 7/10 (back pain)
Recognize cues: What cues are the priority for the nurse to recognize?

Answer

The nurse should recognize that the patient is experiencing severe 7/10 back pain. The rest of the patient’s vitals are currently stable.

Case Study 30.4.2 §30.4 source ↗

Refer back to Chapter 19 Oxygenation and Perfusion, Chapter 22 Activity, Chapter 24 Skin Integrity, and Chapter 26 Urinary Elimination for Unfolding Case Study Parts 1 to 7 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Flow Chart 1730: Assessment
Blood pressure: 132/80 mm Hg
Heart rate: 94 beats/minute
Respiratory rate: 18 breaths/min
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 94 percent on room air
Pain: 7/10 (back pain)
Analyze cues: What subjective and objective information would the nurse want to obtain about the recognized cues?

Answer

To gather subjective information about the patient’s pain, the nurse should perform a “PQRSTU” assessment. During this assessment, the nurse can get more information about what makes the pain worse or better, what the pain feels like, where the pain is felt, how severe the pain is, when the pain started, and what the patient thinks is causing the pain. Objective information would be gathered by checking vital signs and assessing for body language that is indicative of pain such as grimacing or moaning.

Case Study 30.4.3 §30.4 source ↗

Refer back to Chapter 19 Oxygenation and Perfusion, Chapter 22 Activity, Chapter 24 Skin Integrity, and Chapter 26 Urinary Elimination for Unfolding Case Study Parts 1 to 7 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Flow Chart 1730: Assessment
Blood pressure: 132/80 mm Hg
Heart rate: 94 beats/minute
Respiratory rate: 18 breaths/min
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 94 percent on room air
Pain: 7/10 (back pain)
Prioritize hypotheses: What do you think might be some contributing factors to the patient’s back pain?

Answer

The patient has a history of osteoarthritis, so the nurse might hypothesize that it could be contributing to some of the back pain. Additionally, the patient could be experiencing distress from being in the hospital that is manifesting as physical pain.

Case Study 30.5.4 §30.5 source ↗

Refer back to Unfolding Case Study #4: Part 8 for a review on the patient data.

Nursing Notes 1800:
Focused pain assessment performed. Patient reports lower back pain rated 7/10 on numerical pain scale that began last night. Patient states, “I think it’s coming from the hospital bed because I can’t get comfortable.” Patient reports the pain is worse with immobility but improves slightly with ambulation.
Provider’s Orders 1830: New orders

• Ketorolac (Toradol) 15 mg IV Q6 hours PRN severe pain

• Physical therapy referral
Generate solutions: What is the rationale for each of the provider’s orders?

Answer

The rationale for the ketorolac is immediate pain control. Ketorolac is an NSAID that is indicated for the treatment of breakthrough pain and is used to manage moderate to severe pain, such as the pain displayed by the patient in this case study. Physical therapy is ordered to help the patient with exercise and movement that may improve the back pain related to immobility.

Case Study 30.5.5 §30.5 source ↗

Refer back to Unfolding Case Study #4: Part 8 for a review on the patient data.

Nursing Notes 1800:
Focused pain assessment performed. Patient reports lower back pain rated 7/10 on numerical pain scale that began last night. Patient states, “I think it’s coming from the hospital bed because I can’t get comfortable.” Patient reports the pain is worse with immobility but improves slightly with ambulation.
Provider’s Orders 1830: New orders

• Ketorolac (Toradol) 15 mg IV Q6 hours PRN severe pain

• Physical therapy referral
Take action: After administering the ketorolac as prescribed, what adverse effects will the nurse monitor for? What assessment findings might indicate the patient is experiencing these adverse effects?

Answer

One of the main side effects of ketorolac is drowsiness, so the nurse should closely monitor for excessive fatigue. The nurse can monitor for this by frequently assessing the patient’s level of consciousness and monitoring for changes. Another major adverse effect is GI bleeding. The nurse will monitor the patient closely for early warning signs such as tachycardia or a decrease in hemoglobin. Ketorolac can also cause Steven-Johnson syndrome, so the nurse should stay with the patient for a few minutes after administering the medication to watch for the development of a facial rash.

Case Study 30.5.6 §30.5 source ↗

Refer back to Unfolding Case Study #4: Part 8 for a review on the patient data.

Nursing Notes 1800:
Focused pain assessment performed. Patient reports lower back pain rated 7/10 on numerical pain scale that began last night. Patient states, “I think it’s coming from the hospital bed because I can’t get comfortable.” Patient reports the pain is worse with immobility but improves slightly with ambulation.
Provider’s Orders 1830: New orders

• Ketorolac (Toradol) 15 mg IV Q6 hours PRN severe pain

• Physical therapy referral
Evaluate outcomes: What assessment findings would indicate effectiveness of the interventions performed?

Answer

Assessment findings that would indicate effectiveness of the interventions include stable vital signs, lower pain score reported by the patient, and lack of body language cues (e.g., grimacing) that suggest pain.

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Problems and answers are adapted from Fundamentals of Nursing by Christy Bowen, Lindsay Draper and Heather Moore, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/fundamentals-nursing/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.