Which patient would the nurse assess as being the greatest risk for sensory deprivation?

A. An electronic record entry: Documenting in the electronic health record involves recording patient information in a digital system for continuity and legal purposes. While important, this does not involve real-time, interactive communication with the oncoming nurse.

B. An acuity rating: Acuity rating involves assessing the severity of a patient’s condition to determine nursing workload or staffing needs. This is an evaluative process and does not constitute the direct exchange of patient care information between nurses.

C. A referral: A referral is the process of directing a patient to another healthcare professional or service for additional care or evaluation. It does not involve the routine handoff of information between nursing staff.

D. A verbal report: Giving a verbal report, often during a shift change or handoff, is the process of exchanging patient-specific information with the oncoming nurse. This ensures continuity of care by communicating current status, recent changes, interventions, and priority needs in real time.

A. Observe for behavioral cues such as facial expressions and body movements: In patients with advanced dementia who cannot verbalize pain, nonverbal indicators such as grimacing, moaning, guarding, restlessness, or changes in posture are reliable signs of discomfort. Systematic observation using validated tools, like the Pain Assessment in Advanced Dementia (PAINAD) scale, allows the nurse to assess pain accurately and guide appropriate interventions.

B. Wait for family members to report if they think the patient is having pain: While family input can provide helpful context regarding the patient’s typical behaviors and responses, relying solely on family reports risks underrecognizing pain episodes and delays timely intervention. Direct observation by the nurse is essential for continuous assessment.

C. Depend only on vital sign changes to determine the presence of pain: Although pain can cause increases in heart rate, blood pressure, or respiratory rate, these changes are nonspecific and can result from multiple causes. Vital signs alone are insufficient to identify pain, especially in older adults who may have blunted physiologic responses.

D. Assume the patient is pain-free unless they verbally express pain: Assuming absence of pain without verbal confirmation risks undertreatment and patient suffering. Many patients with advanced dementia cannot communicate verbally, so proactive observation and assessment are required to identify and manage pain effectively.