New Era University

#9 Central Avenue, New Era, Quezon City

1107 Metro Manila
COLLEGE OF NURSING
Fernandez, Patricia Andrea Alexei CON 1D
NCM101-18 HEALTH ASSESSMENT

MODULE 7: PAIN ASSESSMENT

Critical Thinking Skills

Juan dela Cruz, 12-year-old, was hit by a car while riding his bicycle. He has several injuries and
is brought to the emergency department at the local community hospital. The senior nursing
student informs the staff nurse that his right leg was splinted at the scene, right pedal pulse was
56, and left pedal pulse was 76. He has a cut above his right eye that is bleeding and his right eye
is swollen and partially closed. Juan has had no loss of consciousness; however, his respirations
are 32 and shallow. He is crying and tells the nurse he has a lot of pain in his right leg, his head
hurts, and he cannot seem to catch his breath. His father is at the bedside and tells him that big
boys don’t cry. His mom is hysterical and keep telling Juan it’s okay to cry.

The emergency department physician asks for a chest x-ray immediately, starts supportive oxygen
therapy, and gives direction for administration of pain medication.

1. How and when should the nurse assess the pain in this patient?
- The nurse should ask him a question to gauge his discomfort and direct observation
of this behavior and physiology responses. The patient’s condition due to collision,
the situation necessitated emergency assessment. Several injuries, wounds,
bleeding, and abnormal vital signs necessitated immediate medical attention.

2. What pain scale tool, if any, would be appropriate to use?

- FACES Pain Scale, mixes visual and adults over the age of three,
- Six faces portray a range of emotions, from pleased to profoundly sad. Each is given
a numerical rating between 0 and 10 (smiling) (crying).

3. What additional information regarding pain is needed?

- The exact site of pain, its degree, frequently, and a description of the pain are all
necessary pieces of information.

4. What role will the parents have at this time?

- The parent’s responsibility would be to assist her son during his therapy by being
present with him, encouraging him, and providing him with the items he required.

5. How do cultural values and belief systems impact the perception and management of
pain?
- The system of cultural values and beliefs has a impact on perception and behavior.
Pain treatment is based on the patient’s perception of suffering and attitudes about
enduring the pain.