A mechanically ventilated adolescent has a RASS score of -3. The child is receiving pain medication and sedation by intravenous infusion. Which action by the nurse is the most appropriate?
A.
Assess the child for uncontrolled pain.
B.
Document findings and continue to monitor.
C.
Increase the fentanyl (Sublimaze) infusion.
D.
Suction the patient in case of tube obstruction.
ANS: B
A RASS score of -3 indicates moderate sedation, which would be appropriate for a child being mechanically ventilated. The nurse should document the findings and continue to monitor. This score does not indicate agitation, so uncontrolled pain should not be an issue. The fentanyl infusion does not need adjustment. There is no indication that the child needs to be suctioned.
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