NACE I PN-RN

Pain is whatever the person experiencing it says it is, existing whenever the person says it does. The client's self-report is the most reliable indicator of pain; normal vital signs do not rule out pain, especially chronic pain, because the body adapts physiologically.

Use a structured assessment such as PQRST (provoking factors, quality, region and radiation, severity, timing) or OLDCARTS. Reassess after every intervention: about 15–30 minutes after IV medication and 30–60 minutes after oral medication.

• Use the WHO-style stepwise approach: non-opioids (acetaminophen, NSAIDs) for mild pain, adding opioids for moderate to severe pain, with adjuvants (anticonvulsants, antidepressants) for neuropathic pain.
• Give analgesics before pain becomes severe and before painful activities such as ambulation or dressing changes.
• For opioids, monitor sedation level before respiratory rate falls: increasing sedation precedes respiratory depression. Use a sedation scale such as POSS.
• Patient-controlled analgesia (PCA): only the client presses the button; family members must not (PCA by proxy can cause oversedation).
• Cold (first 24–48 hours of an acute injury) reduces swelling and pain; apply covered ice 15–20 minutes. Heat relaxes muscles and is used later for chronic or muscular pain.
• Other comfort measures: repositioning, distraction, guided imagery, relaxation breathing, massage (not over injured areas or reddened bony prominences), music, and TENS.

Falls are a leading cause of injury in hospitals and long-term care. Assess fall risk on admission, after any change in condition, and after a fall, using a tool such as the Morse Fall Scale.

• Keep the bed in the lowest position with wheels locked, call light and personal items within reach, and nonskid footwear on.
• Use scheduled toileting for clients with urgency or nocturia, the most common reason clients get up alone at night.
• Use night lights and clear pathways; reorient confused clients often.
• Raising all four side rails is a restraint and increases fall injury when clients climb over them; use two upper rails unless policy states otherwise.
• Review medications that raise risk: sedatives, opioids, antihypertensives, diuretics, anticholinergics.

• Use only as a last resort after documented, failed alternatives: frequent observation, sitter, diversion, covering IV sites with a sleeve, bed or chair alarms.
• Require a provider order that is time-limited; PRN restraint orders are not permitted.
• Tie to the bed frame (moves with the bed), never to side rails, using a quick-release knot; allow two fingers between the restraint and the skin.
• Assess circulation, skin, and need for toileting, food, and fluids at least every 2 hours (more often per policy), and remove restraints as soon as possible.

Examples: an indwelling urinary catheter or IV catheter is a portal of entry; hand hygiene and PPE interrupt the mode of transmission; vaccination and good nutrition reduce host susceptibility.

• Alcohol-based hand rub is preferred for routine care: apply enough to cover all surfaces and rub until dry (about 20 seconds).
• Wash with soap and water when hands are visibly soiled, after caring for clients with Clostridioides difficile or norovirus, and before eating or after using the restroom. Rub for at least 20 seconds.
• Gloves never replace hand hygiene; perform hand hygiene before applying and after removing gloves.

Remove PPE at the doorway or in the anteroom, and remove a respirator after leaving the room and closing the door. Perform hand hygiene immediately after removing all PPE and any time hands become contaminated during removal.