Pain assessment- what do you use?

  1. To all you home care nurses....I need ideas on quick, pain assessments for home care nurses. My agency did a study and seems we fall out in the area of pain assessment. Nurses are assessing pain on the first visit...then it seems to seldom be mentioned again. Oh please not another FORM!!!! That's what I hear from the nurses. We use outcome planners and they seem to lack follow up on the pain. Any words of wisdom or sites that might give me inspiration on a new, simple way for us to assess pain, would be appreiciated.
    •  
  2. 9 Comments

  3. by   nursemicke
    Adventist Home Health will give you a free pain assessment form. I got mine from myhomehealth.
    Last edit by nursemicke on Jul 24, '02
  4. by   hoolahan
    Patti, we simply added this to our nurses notes..

    Pain _____________________________________________

    I use the 0-10 scale for pain assessment, unless the pt can't answer, or language barrier, then I have a faces pain chart. For anyone who has pain, you must assess if their current regimen is effective. So if I have a pt who has chronic back pain, I write

    Pain Chronic/back/arthrtic relieved w current pain med regimen
    Or
    Pain Chronic/back/arthritic; client does not take pain meds as rx.
    Then I document pain management and med instruction and write to assess pain on the next visit.
    Or
    Pain 5 (0-10 scale) abd inc site, has not taken pain med yet
    Or, if they did take pain med, I would call the doc if pain is unrelieved, and/or document any other pain mngmnt measures I did like guided imagery, ice (to a TKR after a PT session for ex), or splinting techniques.

    If you make it a parameter to eval on your notes, then nurses should write an entry every visit, so it won't be missed. An inservice on pain assessment and management, and how to document this info is really what you need. Having a form doesn't mean people will use it, better to teach them how to assess and manage pain.
  5. by   Fgr8Out
    Also, include a pain "goal"... meaning, at what level of pain can a patient perform needed tasks, ie: cough/deep breathe, ambulate or other daily activity. Sometimes, it's impossible to have a goal of "0" but perhaps a patient can be more productive if they are say, a "2" or "3"... For example: Patients present pain level is "5"... goal in order for patient to perform ADL's, 2/10 (2 out of a possible 10).

    Again, I would encourage reading Margo McCafferty...
  6. by   nursemicke
    Patti,
    Was the pain assessment form that I faxed helpful?
    Anne
  7. by   PattiRN
    Anne...thanks so much..very helpful
  8. by   Sleepyeyes
    Also, our form asks what an acceptable level of pain is for chronic pain. Some people say a 5 is just fine, others don't wanna go over a 3. Just for baseline purposes.
  9. by   juliesosarn
    We also added a line to our nursing note with four parts:

    Pain (0-10): Location: Duration: Quality:

    Our plan of care generally has a goal like :States pain at tolerable level of <3 on 0-10 scale w/in 2-3 wks and throughout tx plan. Something like that but the timeframe and <3 may change from patient to patient.
  10. by   nursecheryl
    At our agency we document pain with every visit under vital signs using the 1 to 10 scale, location, intensity, intervention, prevention, outcome etc
  11. by   luvbeinganurse
    We also have a place on our forms to document pain at each visit with basically the same info as you, Cheryl. We also have a pain assessment sheet in the home folder that anyone discipline can write on during their visits with this info, and then when the patient is discharged, the last person out brings the form back for the chart.

close