[bobnurse]

Can anyone share with me their forms or documentation of pain assessment.......most importantly how you document your reassessement?

Thanks

Bobby

[sassynurse78]

We have a form we use, it asks questions like where is the pain, how long it lasts, words to describe the pain such as sharp, throbbing etc. meds used, did the meds help etc. I cannot remeber all the questions, but we use the form for all new pts, any pt that has had a condition change or new reports of pain.

[Angie O'Plasty, RN]

We use a flow sheet to document that. If the Pt. initially states that the pain level is 8, we chart that, then there's another box on the bottom for the reassessment and we chart the later number--4.

If there's no relief, we put an asterisk and chart in the nursing notes what the pain level was and what we did about it.

[Sarah, RNBScN]

We use the pain scale 1 - 10 for adults and faces for children.

We document the pain scale, assess individual and give appropriate analgesia for discomfort.

Forms that we would have would be for our post ops on PCA pumps, etc... If you want to see forms like that, let me know and I can email them to you.

Sarah

[rasheem1]

Originally Posted by Sarah, RNBScN

We use the pain scale 1 - 10 for adults and faces for children.

We document the pain scale, assess individual and give appropriate analgesia for discomfort.

Forms that we would have would be for our post ops on PCA pumps, etc... If you want to see forms like that, let me know and I can email them to you.

Sarah

Sarah I rasheem1 would like to see the form you use my e-mail addrees is lillian949@yahoo.com

[renalnurseeducator]

Originally Posted by Sarah, RNBScN

We use the pain scale 1 - 10 for adults and faces for children.

We document the pain scale, assess individual and give appropriate analgesia for discomfort.

Forms that we would have would be for our post ops on PCA pumps, etc... If you want to see forms like that, let me know and I can email them to you.

Sarah

Sarah I would like to see the forms you use for pain documentation, please email me. Thanks

[LPNer]

Our flow sheets have spaces for:
Pain

• Where
• Level (0-10)
• Intervention
• Comment

Another area of the flow sheet has:

Response

• Level (0-10)
• Respirations
• Comment

Of course both areas have time, etc.

The flow sheet also has area for PCA neuro checks and epidural neuro checks. The PCA area has spaces for attempts/doses etc. to evaluate more easily it's success on pain control or need for further pt educatio on it's use.

I do love our flow sheets, cuts down on the narrative so effectively!

[Traveler]

In home health we also have a section on our notes similar to what Sassy described. We use the 1-10 and FACES. If pain is a focus of the visit or a problem with the patient I also document sleep, psychosocial changes with the patient/family relationships b/c of the pain, changes in daily activities because of the pain, how long pain has been there (days, months, years, etc.) and past methods of dealing with it.

[renalnurseeducator]

Originally Posted by LPNer

Our flow sheets have spaces for:
Pain

• Where
• Level (0-10)
• Intervention
• Comment

Another area of the flow sheet has:

Response

• Level (0-10)
• Respirations
• Comment

Of course both areas have time, etc.


The flow sheet also has area for PCA neuro checks and epidural neuro checks. The PCA area has spaces for attempts/doses etc. to evaluate more easily it's success on pain control or need for further pt educatio on it's use.

I do love our flow sheets, cuts down on the narrative so effectively!

Sounds great! Would I be able to get a copy of your flow sheet?

[safewaygreenbox]

We have pain and sedation assessment on our obs charts (surgical unit)

For pain our assessment is based on
none
mild
mod
severe

this is decided by the patient on movement at same times of other observations.

Kay the 2nd