A nurse makes the following statement during a change-of-shift report to another nurse. “I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair.” What can the nurse who is beginning a shift do to validate the previous nurse’s assessment findings when she conducts rounds on the patient? (Select all that apply.)
- The nurse asks the patient to rate his pain on a scale of 0 to 10.
- The nurse asks the patient what caused his fall.
- The nurse asks the patient if he has had pain in his back in the past.
- The nurse assesses the patient’s lower-limb strength.
- The nurse asks the patient what pain medication is most effective in managing his pain.
The correct answer and explanation is:
The correct answers are:
1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 4. The nurse assesses the patient’s lower-limb strength.
Explanation:
When a nurse conducts rounds on a patient, it is essential to validate and verify the information provided in the previous shift’s report. This is done to ensure accurate and up-to-date assessments, which are critical for patient care. Here’s why the selected options are the most appropriate for validating the findings:
- Asking the patient to rate his pain on a scale of 0 to 10 is a direct way to assess the patient’s pain at the time of the new nurse’s shift. Pain can fluctuate over time, and this allows the new nurse to evaluate whether the patient’s pain is consistent with the previous report or has changed. It also provides a more accurate assessment, as pain intensity can vary from person to person.
- Assessing the patient’s lower-limb strength is important to confirm any possible impairment, especially if the patient has difficulty moving or transferring. The report mentions that the patient “moves slowly as he transfers to a chair,” which may be due to weakness or pain. By assessing the lower limbs, the nurse can verify whether the patient has any deficits in strength that might be contributing to these difficulties.
Why the other options are less useful in this context:
- Asking the patient what caused his fall is unlikely to provide additional validation of the initial assessment findings, as the nurse who performed the previous assessment has already gathered information about the fall. Unless the patient’s memory of the incident is questioned or needs clarification, asking this question may be redundant at this stage.
- Asking the patient if he has had pain in his back in the past may provide some historical context, but it doesn’t directly validate the current assessment. The priority is validating the current condition, especially since this is a new shift, and pain levels and mobility can change.
- Asking the patient what pain medication is most effective in managing his pain might be relevant for planning treatment, but it does not directly validate the assessment findings. The focus should be on assessing the current status of the patient’s pain and functional ability rather than just medication efficacy at this point.
Therefore, 1 and 4 are the best choices to validate the previous nurse’s assessment.