Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols.ĭecreased interest in activities, social gatherings, or old routines Key performance indicators (KPIs) to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record (EHR) design played a role in low compliance with the reassessment of pain. The study concluded compliance rates for the 30-minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion.Īccording to one performance and improvement outpatient project in 2017, areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers. Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. As nurses, you should be aware of the many factors that can influence the patient's pain. Pain is anything the patient or client states that it is to them. Pain assessment may be subjective and difficult to measure. Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. ![]() The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. ![]() Subjective and objective data collection are an integral part of this process. It is the first step in the successful evaluation of a patient. The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data sorting, analyzing, and organizing that data and the documentation and communication of the data collected.
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