An older woman had hip replacement surgery 1 day ago, and the nurse thinks that the woman also has dementia. Which patient assessment does the nurse use to determine whether this wom-an is experiencing pain?
a. Holds abdomen tightly. c. Is not verbalizing.
b. Has stable vital signs. d. Moves during sleep.
A
Because this older adult has a potential cognitive impairment and is likely to self-report pain un-reliably, the nurse uses additional clinical indicators to detect pain. Muscle rigidity and guarding are clinical indicators of pain for a postoperative older adult, regardless of a cognitive impairment. An individual experiencing pain is unlikely to have stable vital signs. Not verbalizing can indicate a sensory impairment and warrants further investigation by the nurse. Nonetheless, this older adult's verbalizations are potentially unreliable indicators of pain. Older adults move normally during sleep to adjust their position in bed; moving during sleep is not an indicator of pain unless the movements are agitated or restless in nature.
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