A nurse is caring for an unconscious patient. What objective ...

[jessicacav]

A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.)
 
  a. Agitation
  b. Restlessness
  c. Sighing
  d. Vital signs
  e. Shivering

Question 2

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

[amy.lauersdorf90]

Answer to Question 1

ANS: A, B, D
The American Society for Pain Management in Nursing's position paper states that for the unconscious, intubated, dementia, or pre-verbal pediatric patient objective assessments of agitation, restlessness, irritation, and changes in vital signs can be used to help assess pain.

Answer to Question 2

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.