which assessment tools should I use on this patient?

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I have an elderly non-english speaking patient that is having constant abdominal pain with unknown cause - in brief he is vomiting and feverish, BP 90/50 and has not had much fluids/solids in the last 48 hours. I'm thinking I should use the numerical pain rating scale as one assessment tool but I need another in order to develop a profile for him. Based on his symptoms what do you think I should use as the second tool? I am not very familiar with many assessment tools so any help will be much appreciated.

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I would definitely use an interpreter as well...

How are you going to ask him what his pain level is? Do u speak his language? You may want to think about using the faces pain scale?

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I forgot to mention that his son is with him and is acting as a translator. Should I consider the falls risk assessment tool considering his BP is low and his son has expressed that he has been confused and forgetful lately

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Do not ever use a family member for a translator. Many will either change what the patient says so as not to tell you anything embarrassing, or the patient will not tell you what you need to know because s/he doesn't want the family member to know. Ask the facility about their interpreter service choices-- there are many.

P.S., don't use the housekeeping lady or the transport guy-- they are likely not to know medical terms and may also be subject to the embarrassment barrier.

Other than that, how about you google "pain scales" and see what choices there are? Which do you think would be best in this situation?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

How do you assess their well being? How do you assess vital signs? How do you assess if they have a fever? How do you assess if they are hydrated? what do you use to know these things?

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Yea..its usually against policy to use family and non-liscenced ppl to do medical interpreting. You must use a facilty approved translator. Falls is good what about Braden score? And definitely what Esme said..always. .

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To be honest with you, I would prioritize this pt's hemodynamic instability above his pain - at least for the moment. I know that "pain" is always the #1 priority on nursing school exams, but honestly, the guy's BP is plummeting and he has s/s of possible sepsis/SIRS. Unless you're working in the ICU and the doc has already addressed this presentation, you need to be on the phone stat and getting the doc to the bedside. You do want to treat his pain quickly, but if you don't rapidly treat the root cause of his presentation, you might end up with a dead pt soon.

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