11.5 Applying the Nursing Process
Open Resources for Nursing (Open RN)
Assessment
Nurses play an essential role in performing comprehensive pain assessments. Assessments include asking questions about the presence of pain, as well as observing for nonverbal indicators of pain, such as grimacing, moaning, and touching the painful area. It is especially important to observe for nonverbal indicators of pain in clients unable to self-report their pain, such as infants, children, clients who have a cognitive disorder, client at end of life, non-English-speaking clients, or clients who tend to be stoic due to cultural beliefs. See Figure 11.14[1] for an image of a simulated client who is expressing pain nonverbally.
Recall that pain is defined as whatever the person experiencing it says it is. Subjective assessment includes asking questions regarding the severity rating, as well as obtaining comprehensive information by using standard measures like PQRSTU or OLDCARTES for assessing a chief complaint. For some clients who are unable to quantify the severity of their pain, visual scales like the FACES scale are the best way to perform subjective assessment regarding the severity of pain. Review the PQRSTU, OLDCARTES, FACES, and other pain assessment scales in the “Pain Assessment Methods” section of this chapter.
Objective data includes observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. For clients who cannot verbalize their pain, using a scale like the FLACC, COMFORT, or PAINAD is helpful to standardize observations across different staff members. Keep in mind that clients experiencing acute pain will also likely have vital signs changes, such as increased blood pressure, increased heart rate, and increased respiratory rate.
It is important to assess the impact of pain on a client’s daily functioning. This can be accomplished by asking what effect the pain has on their ability to bathe, dress, prepare food, eat, walk, and complete other daily activities. Assessing the impact of pain on daily functioning is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the client’s situation. For example, for some clients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other clients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal.[2]
When performing a client assessment, any new complaints of pain or pain that is unresponsive to the current treatment plan should be reported to the health care provider. Instances of sudden, severe pain or chest pain/pressure require immediate notification or contact of emergency services.
Diagnoses
Commonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than three months) and Chronic Pain. See Ta