Case Study, Chapter 9, Assessing Pain: The Fifth Vital Sign

James Henderson is 52 years old. He started to experience pain in his right knee 1 year ago,

when he noticed he was having difficulty climbing steps. He has had a very active life. Mr.

Henderson played baseball throughout his childhood and entered college on a baseball

scholarship. He exercises daily and works as a coach for a minor league baseball team, which

requires him to run daily while training the players. He has always been proud of his athletic

ability, so he dismissed the knee pain as simple soreness from overuse while exercising. After a

medical examination, it was determined that Mr. Henderson would need a total knee

replacement. The damage to his knee was extensive, and the surgery was required to allow Mr.

Henderson to continue his active lifestyle to some degree. He was devastated and thought of the

implications this would have on his career. He is now in the postanesthesia care unit (PACU)

after having undergone a total knee replacement. The endotracheal tube has not yet been

removed. He appears restless.

VS: BP 144/82, HR 96, RR 24, Pulse Ox 98%

(Learning Objectives 4, 7)

Questions:

a. Based on the information gathered, how should the nurse assess Mr. Henderson’s pain

level?

b. Once the nurse has completed the assessment, what actions should be taken?