A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action?
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis. The client's self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse's subsequent interventions (Option 3)
(Option 1) An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority action.
(Option 2) If the client's attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain assessment.
(Option 4) The client learns how to use the IV PCA pump when it is initiated. The nurse should reassess the client's knowledge level regarding proper use and reinforce previous teaching. However, it is not the priority intervention.
Educational objective:
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis, assesses the client's knowledge level regarding its use, and reinforces previous teaching.
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis. The client's self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse's subsequent interventions (Option 3)
(Option 1) An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority action.
(Option 2) If the client's attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain assessment.
(Option 4) The client learns how to use the IV PCA pump when it is initiated. The nurse should reassess the client's knowledge level regarding proper use and reinforce previous teaching. However, it is not the priority intervention.
Educational objective:
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis, assesses the client's knowledge level regarding its use, and reinforces previous teaching.
