Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.

A. Difficulty swallowing. While difficulty swallowing (dysphagia) can be associated with certain conditions, it is not a typical indicator of unrelieved pain in a client receiving a spinal epidural. This symptom may be related to neurological involvement or medication side effects and should be assessed further.
B. Constipation. Opioids used in conjunction with epidural anesthesia can contribute to constipation, but this is a side effect rather than a direct indicator of pain. Constipation can also result from reduced mobility or decreased fluid intake, so it should be managed appropriately but does not necessarily reflect uncontrolled pain.
C. Urinary retention. Epidural anesthesia can affect bladder function by impairing the sensation of fullness and the ability to void. While urinary retention is a common side effect of epidural use, it is not a direct sign of unrelieved pain. Monitoring for bladder distention and assessing for the need for catheterization is important.
D. Clenched teeth. Clenching the teeth is a physical manifestation of pain, often indicating discomfort and distress. Clients experiencing unrelieved pain may also exhibit other nonverbal cues such as grimacing, restlessness, or guarding. The nurse should assess pain using an appropriate scale and notify the provider if pain is not adequately controlled.

A. Evaluate the need for the client to remain in mitten restraints. Assessing the necessity of restraints is a nursing responsibility that requires clinical judgment. Nurses must evaluate the client's condition and determine if restraints can be discontinued or if alternative measures are appropriate.
B. Assist the client with range-of-motion exercises of the hands. Assistive personnel (AP) can perform tasks that promote mobility, such as passive or active range-of-motion exercises. These exercises help prevent stiffness and maintain circulation in restrained extremities.
C. Determine the circulation status of the affected extremities every 2 hr. Assessing circulation involves evaluating capillary refill, skin color, temperature, and sensation, which requires nursing assessment skills. This task should be performed by a nurse rather than delegated to an AP.
D. Instruct the client's family about the purpose of mitten restraints. Educating the family on medical interventions falls within the nurse’s scope of practice. The nurse must explain the rationale, risks, and alternatives to ensure family members understand the need for restraints.