Which parameters does the nurse include when assessing pain? (Select all that apply.)
a. Facial expression
b. Muscle spasms
c. Shallow respirations
d. Immobility
e. Temperature
ANS: A, C, D
Some objective observations can be helpful in indicating pain, although they are not as reliable as the patient's report. These include facial expression, shallow or rapid respirations, increases in respiratory and pulse rate, and increased blood pressure. The patient may also be reluctant to move if he/she is in pain. Temperature is not affected.
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