As we are concerned with Juanita Nelson’s consistent severe pain and lack of a scheduled pain medication regimen we would first contact her physician.


  • This is a third year nursing student from Surgery 5000 and I am calling about Juanita Nelson in room 5050. The problem that I am calling about is Mrs. Nelson’s consistent pain that seems to be significantly increasing her anxiety and is having negative effects on her both physically and mentally. She has not yet been able to be free of pain while being on prn morphine and does not have any other pain medications ordered.
  • Although she is unable to rate her pain level, she continually demonstrates moaning, grimacing, and guarding. I have been working with her for a couple of days now and it is becoming a trend.
  • I have just assessed the patient personally and her vital signs are: Blood Pressure: 149/88, Pulse: 122  Respirations: 32 and Temperature is 36.5°C.


  • I think the problem is an inappropriate pain management regime. Mrs. Nelson's pain is poorly controlled and has been unrelieved.


  • I would like to see a scheduled pain management regime developed for Mrs. Nelson as evidence has shown that consistent pain is best managed with an round-the-clock pain management regime.
  • I am requesting a referral to palliative care in order to have Mrs. Nelson's pain thoroughly assessed. This assessment will allow Mrs. Nelson and her family to discuss possible pain interventions and will direct the development of a specific pain regime. At this time it would also be useful for both a physician and nurse to be present to discuss the assessment with palliative care.
If we are better able to manage her pain, her anxiety will decrease, we can increase her activity level, she will be able to cope better with her situation, and be orientated enough to visit with her husband when he comes in. This regime will decrease the likelihood of an adverse event resulting from anxiety due to pain.

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