The nurse is assessing a patient who is unable to supply a self-report of pain. What should the nurse do to assess the patient's pain?
1. Use a surrogate pain rating from the family or caregiver.
2. Document that the client cannot scale the pain.
3. Document the client's pain using a numeric rating scale.
4. Use the McGill pain questionnaire to assess the pain.
1
Rationale 1: Using a surrogate pain rating from caregivers and family is an acceptable assessment strategy for at-risk patients.
Rationale 2: Documenting that the patient cannot scale pain is not an assessment tool.
Rationale 3: The patient who cannot report pain will be unable to use the numeric rating scale.
Rationale 4: The patient must be aware and able to answer questions regarding pain and quality of life to use the McGill pain questionnaire.
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