A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the findings and continue to monitor.
d. Try a small dose of analgesic medication for pain.
ANS: A
Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.
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