The nurse is caring for a client post-op day 1 for a bowel resection. The client is receiving pain medication via a patient-controlled analgesic pump (PCA) but states that her pain is severe and the pain pump is not providing adequate relief. Which is the priority nursing action for this client?

  • assess vital signs and pain for location, quality, and intensity
  • reposition the client with the head of bed elevated 30 degrees
  • offer nonpharmacologic pain relief measures since the medication dose cannot be increased
  • press the PCA button to deliver a bolus and ask family members to press the button for the client if she is asleep
Number 1 is correct.
The first priority is to evaluate pain, including vital signs. Clients on a PCA must have vital signs monitored regularly due to the risk of respiratory depression from oversedation. The nurse can contact the health care provider with this information for further orders. Repositioning the client may increase comfort but is not the first priority for this client with severe pain. Nonpharmacologic measures are not likely to offer much relief to this client, and the nurse should not assume that dosages cannot be adjusted. In teaching the client and family proper use of the PCA, emphasis should be placed on the client being the only one to administer pain medication in order to avoid oversedation. If the client is unable to use the PCA, other means of pain relief should be considered.