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The nurse is admitting the patient to a medical unit. She is 68 years of age...

The nurse is admitting the patient to a medical unit. She is 68 years of age and has a history of ovarian cancer. She had surgery 5 months ago and has had pain ever since the surgery. She reports that she has been taking oxycodone hydrochloride/acetaminophen (Tylox) tablets at home but that the pain is “never gone.”

The patient describes her pain as a “10” on a scale of 0 to 10, deep, occasionally cramping, and sharp or stabbing. She waves her hand over her chest and abdomen when asked to pinpoint the location of the pain.

  1. How should the nurse document this assessment of pain
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Answer #1

The assessment of pain can be documented in subjective and objective data.

Subjective data: it refers to what the patient refers Here it can be stated as patient complaints I have severe pain on abdomen and chest.

Objective dats: refers to what the nurse observes. It can be stated as

* pain score of 8

  1. * surgical incision present on the abdomen
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