Look Back: Pain Assessment

Look Back

A meaningful event from my clinical experience was during week four when my RA and I along with the nurse helped a client who had an unwitnessed fall. I came back to the unit after my break, and then it was my colleague’s turn to go for her break. We had to monitor each others clients during break time. Before she left, she told me that her client is in his room having breakfast and let her know about the client’s foods and drinks intake. He needs one-person assistance and he uses walker. She also told to assist the client to take off his pajamas and change into day clothes if he allows. I went along with another colleague to the client’s room, he was just sitting on the couch and he ate 25% of the foods and drank half cup of juice.

I didn’t get his respiratory rate because he was moving. The nurse did pain assessment objectively because client was responding when asked to rate pain level. Client wasn’t showing any physical or facial signs of pain. According to LeMone, “Glasgow Coma Scale is used to assess behavior, including actions and affects, content and quality of speech, and level of consciousness.” (p. 1421) The nurse followed the Head Injury protocol of the facility and performed the head injury assessment on the client. She used penlight to see if the pupils dilates or constricts. Client’s pupils were reactive to the light and it constricted which was a good sign. The nurse said she would monitor the client and do a follow-up

Elderly are very prone for falling because of their age and health conditions. Nurses have to take appropriate steps for client’s safety and health. For example, taking vital signs and performing assessment after the injury for any changes in client’s level of consciousness. According to RNAO (Prevention of Falls and Fall Injuries in the Older Adult), nurses’ need to monitor and make frequent visits to clients’ room to prevent falls. Nurses should observe client’s behavior and needs to keep close observation on clients who are at high risk for fall. Especially the clients, who use walkers, nurses and staffs should remind them to use walkers at all time and tell them to call bell if they need anything. Make sure that clients wear eyeglasses if they have, wear proper shoes and their environment should be kept clutter free. Nurses can encourage clients to do stretches and exercises to strengthen leg muscle and take vitamin supplements if they need it. To decrease falls, always position the bed to the lowest height and non-slip mattress that is also