basic nursing question


What do you document if your patient is unconscious and you need to put what their pain is from a scale of 1-10? there is not a place to put "unobserved".

Specializes in ER, Step-Down. Has 2 years experience.

at our facility we have the option "unable to assign a number" and then we can choose "behavioral cues" and leave a comment or NVPS (non-verbal, paralyzed, sedated) as the scale type if we can't assign a number. This is, of course, with electronic charting (Epic to be exact).

Specializes in Telemetry, CCU.

There are different pain scales that you can use for the unconscious patient, such as FLACC and Wong-Baker FACES. These scales use non-verbal cues such as grimacing, moaning, restlessness, etc. If the patient is sedated with something that doesn't have analgesic properties, such as Diprivan, but the patient is assumed to be in pain (post op for example), it is okay to document it as such, presume the pt to be in pain, and medicate him.

vashtee, RN

1,065 Posts

Specializes in DOU.

We use the FLACC scale which assigns a numeric value to various physical cues such as frowns, grimaces, legs restless, crying, etc. Like the numeric scale, 10 is the highest number possible.

Specializes in ICU, CM, Geriatrics, Management. Has 17 years experience.

Ditto above.

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