Charting Pain Assessment

Nurses General Nursing

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

(I posted this originally on the Pain Management Forum but it didn't seem to be getting a lot of looks and thought I'd try cross-posting here - Thanks!)

Hello everyone,

I'm a clinical manager at my hospital attempting to revises the way we assess pain and pain control. Although I know mostly what I would like to see I'm also cognizant of the workload most of the staff have (anywhere from 6-9 pts each) and am trying to develop something that does not dramatically increase the workload (I find that the more you try to add on the less reliable the added work is).

So, to that end - this is currently how we assess pain:

Pain - present or absent

6 pain sections (only chart on the number of places pt has pain - ex if pain present in abd and legs you would chart on pain#1 and pain #2)

Pain Location

Pain intensity

Pain description

Accompanying symptoms

Reassess pain intensity

Consciousness Scale

Respiratory Scale

Motor Block for epidurals

PCA/epidural Med

Concentration

Dose

Lockout

Basal

Bolus

Attempt number

Number of doses given

Number of bolus

Total given ml

Total drug given (mg or mcg)

total remaining

Narcan given?

New syring hung

Tubing change

Intervention

Intervention response

All of this charting exists under our assessment portion (computer charting) as is usually charted on 1 time per shift. The medications (other than pca/epidural) are charted on another screen and do not flow across. So, for example if dilaudid is given it is charted on the electronic MAR and thenyou have to click on another screen to see what the pain score is and whether or not relief was achieved (often times not charted on or somehow charted at the same time as the original pain score was charted). This leads to a very fragmented system of pain assessment and I believe leads to inneffectual pain relief.

So to make a long story short (too late) this is what I would like to change. I like a lot of what the assessment asks for but I think realistically it is too much for the floor staff to do each time they give a pain med. What I would like to do is develop a new screen that could be charted on when a pain med is given - something relatively simple that pain relief can easily be gauged from. The assessment above can not even be viewed on the same screen at one time, you have to keep scrolling down.

So finally my question, what are the essential questions that need to be asked when documenting a pain med? These are my thoughts already:

Pain intensity

Pain med given / dose

or

Alternative Intervention tried

Did you receive adequate pain relief last time from this treatment?

Acute pain or Chronic pain

and if on a PCA at least every 2 hrs for 1st 24 or longer if pain not relieved

#attempts

Actual dose received

Any other ideas or suggestions - please remember I want to simultaneously achieve good pain relief and not overburden the floor staff with documentation. Also I would have them chart on the assessment located at the top q 4hrs until pain relief achieved and the q 8 hrs.

Thanks in advance

Pat

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

Bump :lol2:

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How in the name of Jesus can anyone take care of 6-9 pts and chart such a complicated pain sheet? Personally, this whole regulatory obsession with pain is a total PITA. Half the time I just make up a G-D88m number on the stupid pain scale.

If I were you I would make the charting the simplest you can get away with and not alert the regulatory nitwits that you are just going through the motions. What ever you have to do to keep from getting sued or making the Jchho inspectors mad.

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(I don't totally 'make up' a number, but I guessimate, based on what the pt says. Why hassle someone for a G-D**m number when they're hurting?)

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Specializes in PCU, Home Health.

at our hospital the PCA info is on a completely different form than the pain assessment when that is in use. We chart every 4 hours about pain assessment, if intervention is given we chart the results within the hour. Does JAHCO need more than that?

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Specializes in PCU, Home Health.
(I don't totally 'make up' a number, but I guessimate, based on what the pt says. Why hassle someone for a G-D**m number when they're hurting?)

I usually just quote what they say in quotes.(lol I guess that is the only way to quote something) Usually if they give me that blank stare after I explain the pain scale I know the number really will mean nothing. I think it is crazy to expect the patient to figure out the pain scale if they state they are in pain. But then again I am not really in charge of running the show.

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I usually just quote what they say in quotes.(lol I guess that is the only way to quote something) Usually if they give me that blank stare after I explain the pain scale I know the number really will mean nothing. I think it is crazy to expect the patient to figure out the pain scale if they state they are in pain. But then again I am not really in charge of running the show.

Yeah, I'm not in charge either. I've never heard any complaints (about my charting), but alot of pts don't like to be hassled for a number with the pain scale. (Or else they are always a 10/10 :rolleyes: )

We don't have a pain sheet, but we'll probably get one when we go to computer charting. We only have one for PCAs and epidurals. I just fill in the blanks as quickly as possible, it's a q 4 hr deal.

I handle that in my nurses notes.

"Pt C/O severe pain in abd, was tearful. Gave 1 mg dilaudid"

Then later...

"Pt resting comfortably without complaints, eyes closed, appears asleep"

or

"Pt reports relief from abd pain"

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Or...

"Pt still reports severe pain, 8/10, that was unrelieved by dilaudid given. Dr Sleepyhead called, new order received"

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My facility uses a very simple pain flow sheet. Date,time,pain scale,med,amt given,HR,RESP,O2SAT pre med,route given, Next is assessment done 30 minutes to an hour post medication. We have a separate PCA/epidural sheet which is way more complicated.

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

I agree that asking someone to chart on the first pain assessment I posted every time their is an intervention is ridiculous which is why I am trying to get it changed. I think the first part could be for their 1-2 times a shift assessment, but I want the actual intervention to be. . . well . . . easy.

I don't think just charting a prog note will work for reviewing how well we are managing pain. I have read recent studies that suggest nurses actually underestimate their patient's pain by 2 points or more. Prog notes would not easily expose this.

I'm hoping that our computer designers can tie the assessment into the pain meds - for example if I go in to give 2 percocet when I scan them into the computer I would like it to bring up another box that asks:

Pain Intensity: {enter value}

Alternatives Tried: {Select from pull down screen, ie heat, cold, reposition

Did you receive relief last time: {yes, no, na}

Is this acute or chronic pain?

Then when you have filled that out and given the meds it would chart on its own screen like this:

2200

Pain Intensity: 6/10

Medication: Percocet 2 tabs

Alternatives: Reposition

Relief with last dose: No

Acute or Chronic: Chronic

Post Pain Intensity 4/10

If they had a PCA then add at bottom

# Attempts: 22

Doses Received: 10

(I can't figure out how to make it look like a cell in excell with the time over the info)

I hope this makes sense to people, what I want is a screen that staff can easily look at and determine if they are doing a good job to control pain. Or you come on to a new shift and you see this charted from the prior shift you could easily know that something needs to be done. Also as management I could easily pull this info and determine if we need to do an inservice on pain control or if I should talk to a specific doctor about the pain meds they order.

However, is their any other info that people think is essential to go on this quick assessment sheet.

Pat

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HA! You think that having a proper computer screen ensures that proper pain control was attained? HA! No, listening to the pt does that, filling out a screen q 4 is just another bookkeeping task for the bedside nurse to do to satisfy the regulatory hounds. The more charting you require, the less accuarate it becomes.

My advise is to make it simple and easy to do and acknowledge with a wink and a smile to your staff that it a neccessary evil. I have a wonderful manager who is very sympathic that we have to jump through these ridiculous hoops and we are sympathetic right back at her. We are very devoted to her and we have a wonderful unit. Our numbers are up on the stupid graph charts that our DON is in love with.

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Specializes in med/surg.

We use a simple scale of 1-10 (with smiley-sad-crying faces for kids). Everytime you do the obs you chart the pain scale on the actual obs sheet, in the box provided. When you write the careplan you chart what the pain was like in your shift & what you did about it.

If the patient calls you inbetween your regular checks because they're in pain you ask them where they'd put that pain on the scale, apply whatever intervention is available, then 20-30 mins later go back to see if it has worked.

It's simple but effective. Pain relief is very good in our hospital & it's very rare for patients to get into difficulty with their pain relief. When they do it' s usually because the anaesthatist/doc hasn't written enough pain relieving options on the drug chart or hasn't set up a PCA in theatre, when they should have.

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