The nurse caring for a female patient 1 day after a thoracotomy assesses that the patient is in pain, but the patient states that she has no pain. Which does the nurse use to confirm the patient's pain?(Select all that apply.)

Question

a. Facial grimacing during linen changes
b. Eats a full liquid diet without assistance
c. Uses the incentive spirometer every hour
d. Patient's culture forbids complaints of pain
e. Has received nothing for pain since sur-gery
f. Heart rate 110, blood pressure 169/90

Answer 1

A, D, E, F
To confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patient's verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patient's culture forbids admitting to pain, necessitating the use of other pain indicators. A thoracotomy usually has a painful postoperative course because the surgical incision is stretched every time the patient breathes; thus a patient who receives no analgesia on the first postoperative day is very unusual. Tachycardia and hypertension are good clinical indicators of pain when the patient expresses contradictory messages about pain. The blood pressure increases because the patient becomes tense and contracts muscle, increasing the force necessary to drive blood through the vasculature. The heart rate increases from the stress response to pain and the resultant surge of epinephrine from the sympathetic nervous system. Eating and breathing deeply are inconsistent with a patient in pain.