NR 304 Week 4 Pain Assessment Write-Up Example

Pain Assessment Write-Up: A 74-Year-Old Retired Florist With Two Broken Ribs, at Rest, on a Deep Breath and on a Cough

Student Name

College of Nursing, Chamberlain University

NR 304: Health Assessment II

Instructor Name

Month Day, Year

Pain Assessment Write-Up: A 74-Year-Old Retired Florist With Two Broken Ribs, at Rest, on a Deep Breath and on a Cough

Setting

Mrs. F. is a 74-year-old retired florist admitted yesterday evening to a medical-surgical unit after slipping on a wet kitchen floor and falling against the edge of a counter. The chest X-ray report in her chart lists fractures of the right 6th and 7th ribs. Her home is a ground-floor apartment where she lives by herself, and she has high blood pressure treated with losartan. This assessment took place at 1015 on hospital day 2. Her last dose of pain medication, oxycodone 5 milligrams by mouth, was given at 0630 according to the medication record, and acetaminophen 1,000 milligrams at 0600.

Pain was measured on the 0 to 10 numeric rating scale throughout, with 0 meaning no pain and 10 meaning the worst pain she can imagine. The same scale was used for every reading, and the question was asked in the same words each time: "On a scale from zero to ten, where zero is no pain and ten is the worst pain you can imagine, what number is the pain in your side right now?" A review of studies comparing pain scales in adults found the numeric rating scale performed well and was generally easier to use than a visual analog scale, while noting that scores from different scales cannot simply be swapped for one another (Hjermstad et al., 2011).

Her Account

Quality, in her words: "It's a stabbing, like somebody's poking me with the end of a broom handle," when she breathes in deeply or coughs; "a dull, heavy ache, like a bruise," when she lies still.

Site: right side of the chest, about a hand's width below the armpit; she pointed with one finger to a spot along the side of the ribs.

Spread: "It goes around toward my back a little"; she traced about 10 centimeters toward her spine along the same level. It does not go into her arm, neck, belly or shoulder.

What makes it worse: "breathing in all the way," coughing, turning to the right in bed, and getting from lying to sitting.

What helps: "holding a pillow against it when I cough" and the pain tablets, which she says "take the edge off for a few hours."

Effect on her: "I'm scared to cough, so I don't," and "I only slept a couple of hours."

Her goal: "To be able to take a proper breath."

Three Readings Under Three Conditions

Reading 1, 1015, lying at 30 degrees, breathing normally, still for 5 minutes beforehand: 3.

Reading 2, 1018, same position, immediately after one deep breath in, asked to take "the deepest breath you can": 7.

Reading 3, 1022, same position, after one cough, holding a pillow against the right side as she chose: 8.

Same question, same words, same scale each time. Between readings, she was allowed to rest for two to three minutes until breathing had returned to the rate at rest.

Reading after a position change, 1030, after moving from lying to sitting on the edge of the bed with help: 6.

Time since last oral pain medicine at reading 1: 3 hours 45 minutes (oxycodone at 0630).

What the Student Saw

Breathing at rest, before reading 1: 22 breaths per minute, counted for one full minute; shallow, with the right side of the chest moving less than the left on inspection.

During the deep breath (reading 2): stopped the breath partway in, winced, closed her eyes, pressed her right hand to her side.

During the cough (reading 3): a short, weak cough; she held the pillow tightly, let out a sound, and her face tightened for about 5 seconds.

Position chosen at rest: leaning slightly to the right side, with her right arm held against her chest.

Moving to sitting: used her left arm on the bed rail, kept her right arm tight to her side, and paused twice.

Oxygen saturation: 94 percent on room air at rest, 1015; 93 percent after sitting, 1030.

Incentive spirometer, used by her at 1035 with coaching: 750 milliliters on her best of three tries; her target on the chart is 1,500 milliliters.

What Changes the Meaning of the Numbers

A resting score of 3 would be easy to read as acceptable pain control, but the resting number is not the one that matters for a person with broken ribs. The deep-breath and cough scores of 7 and 8, together with the shallow breathing, a weak cough, and an incentive spirometer volume half of her target, show that the pain is limiting the two things she most needs to do. Bulger et al. (2000) studied older adults admitted with rib fractures and found higher rates of pneumonia and death than in younger patients with the same injuries, with each additional broken rib adding risk. That is the reason the write-up treats the cough reading as the key figure. The student does not claim that pneumonia is present or likely in Mrs. F.; the point is that the readings under movement tell the team whether she can clear her lungs.

The timing of her last dose matters too. The readings were taken nearly four hours after oxycodone, and a set repeated about an hour after the next dose would show whether the medication changes the deep-breath and cough scores, not only the resting one.

Report and Plan for Reassessment

At 1040 the student reported to the primary nurse, giving all three readings together with their conditions, the spirometer volume, and her statement that she is afraid to cough. The primary nurse contacted the provider about the pain plan. The student will repeat the same three readings, with the same question and scale, 60 minutes after the next dose of pain medication, and will record them beside this set so the two can be compared directly. Mrs. F. was shown again how to hug the pillow while coughing and was encouraged to try the spirometer ten times an hour while awake, as ordered.

Reflection

The first draft of this write-up said that the patient reports severe pain with breathing. Severe was not her word, and it removed the difference between her stabbing pain on breathing and her dull ache at rest. Jarvis and Eckhardt (2024) list the character of pain as one of the core elements to record, and keeping her words turned out to carry information that no number did. The other change was taking the readings minutes apart with the same words. The first time the student asked, the second question was how bad is it when you breathe in, and she answered really bad rather than a number. Asking the identical question each time gave three numbers that can be compared, and the comparison is the finding.

References

Bulger, E. M., Arneson, M. A., Mock, C. N., & Jurkovich, G. J. (2000). Rib fractures in the elderly. Journal of Trauma: Injury, Infection, and Critical Care, 48(6), 1040-1047. https://doi.org/10.1097/00005373-200006000-00007

Hjermstad, M. J., Fayers, P. M., Haugen, D. F., Caraceni, A., Hanks, G. W., Loge, J. H., Fainsinger, R., Aass, N., & Kaasa, S. (2011). Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review. Journal of Pain and Symptom Management, 41(6), 1073-1093. https://doi.org/10.1016/j.jpainsymman.2010.08.016

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.