A patient with developmental disabilities and poor verbal communication skills has been admitted for observation after a motor vehicle accident. The patient has been moaning, facial grimacing, and restless since being admitted to the floor
The nurse needs to first assess the patient for which of the following? a. Safety, because the patient will not use the call light
b. Hydration, because the patient is not able to verbally communicate his or her needs
c. Bathroom privileges, because of lack of communication skills
d. Pain, because the patient is unable to communicate effectively
D
Patients unable to communicate effectively often require special attention during assessment. Some examples are the following:
• Infants and children
• Patients who are critically ill and/or unconscious
• Patients with dementia
• Patients who are mute or aphasic
• Patients with an intellectual disability
• Patients at the end of life
These patients all require different assessment approaches. However, be alert for subtle behaviors that indicate pain. Note a patient's vocal response (e.g., moaning, crying, gasping), facial movements (e.g., grimacing, clenched teeth, tightly closed eyes), and body movements (e.g., restlessness, increased hand and finger movements, pacing), or inactivity. While the other responses are appropriate, the patient is currently exhibiting signs of pain, making it the priority.
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