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1.
The numerical rating scale to assess pain should not be used for those who cannot quantify the severity of their pain (i.e., a patient who has difficulty communicating). Another scale that assesses pain in a nonverbal person should be used to quantify the patient’s pain. The numbers assigned to the patient’s pain may not be accurate because of his aphasia.
2.
Pain medications were given at 14:45 and not reassessed within one hour; pain was not at target pain goal at 16:10, but no additional pain interventions were enacted; pain score and pain goal were left blank at 20:10; pain was not reassessed after 20:10 intervention.