Saturday, November 27, 2010

Pain Management p 232 17th Edition CPNE Excelsior Study Guide

ask patient to rank pain:
  • Adults on scale of 0-10,  or a visual analog scale
  • child of 3 or older use the faces 0-5 or visual analog
  • 2 months to 3 years use the FLACC
  • observing behavior indicative of pain
assess patient's pain location by asking the patient to point to the location of the pain
  • if the patient is unable to verbalize or communicate location observe
    • pulling on ear
    • limping
    • rubbing  an area
assess the quality of the pain by asking the patient the characteristics of the pain
  • sharp
  • dull
  • stabbing
  • aching
  • throbbing
assess the duration of pain by asking the patient:
  •  how long does the pain last
  •  how often does it occur
  • how long have you experienced this pain
provide three of the following pain relief measures
  1. repositions the patient or assists the patient to a different position
  2. gives the patient a back
  3. uses relaxation and/or distraction techniques
    1. guided imagery
    2. watching TV
    3. drawing a picture or coloring
    4. engage in conversation about a happy memory or hobby
    5. pacifier
    6. cuddling
    7. play
    8. singing
  4. applies heat or cold when assigned
  5. administer pain med when assigned, or
  6. if not assigned request the primary nurse to administer pain med
reassess the patient's pain by:
  • asking the adult patient to rate the pain on a scale of 0-10 or visual analog scale
  • asking the child of 3 or older to rate the pain on a 0-5 Faces scale or visual analog scale
  • using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age
  • observing behavior indicative of pain in an infant or noncommunicating- adult or child
    • moaning,
    • grimacing
    • clutching
    • restlessness
  • level of pain
  • location of pain
  • intensity of pain
  • duration of pain
  • characteristics of pain
  • predisposing factors
  • aggravating factors
  • measures to relieve pain
  • patients response to measures to relieve pain

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