Pain management log for: _____________________________________________________________ Please use this pain assessment scale to fill out your pain control log. |_____|_____|_____|_____|_____|_____|_____|_____|_____|______| | | | | | | | | | | | 0 1 2 3 4 5 6 7 8 9 10 No Worst pain pain _____________________________________________________________ |Date | Time | How | Medicine or | How | Activity at | | | |severe is| non-drug |severe is| time of pain | | | |the pain?| pain control| the pain| | | | | | method |after one| | | | | | | hour | | |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________| |_____|______|_________|_____________|_________|______________|Initial Pain Assessment Tool
Date:________________
Patient's name:_______________________ Age:________ Room:_______
Diagnosis:____________________________ Physician:_______________
Nurse:_______________
I. Location: Patient or nurse marks drawing
II. Intensity: Patient rates the pain. Scale used: ___________
Present:__________________________________________________
Worst pain gets:__________________________________________
Best pain gets:___________________________________________
Acceptable level of pain:_________________________________
III. Quality: (Use patient's own words, e.g., prick, ache, burn,
throb, pull, sharp)
__________________________________________________________
IV. Onset, duration, variations, rhythms:_____________________
__________________________________________________________
V. Manner of expressing pain:________________________________
VI. What relieves the pain?___________________________________
VII. What causes or increases the pain?________________________
VIII. Effects of pain: (Note decreased function, decreased quality
of life.)
Accompanying symptoms (e.g., nausea)_______________________
Sleep______________________________________________________
Appetite___________________________________________________
Physical activity__________________________________________
Relationship with others (e.g., irritability)______________
Emotions (e.g., anger, suididal, crying)___________________
Concentration______________________________________________
Other______________________________________________________
IX. Other comments:___________________________________________
X. Plan:_____________________________________________________
__________________________________________________________
Note: May be duplicated and used in clinical practice
Source: McCaffery and Beebe, 1989. Used with permission.
[2] Possibilities for other columns: bowel function, activities,
nausea and vomiting, and other pain relief measures.
Identify
the side effects of greatest concern to patient,
family,
physician and nurse.
Flowsheet for pain management documentation
Patient_______________________________________________Date:__________
Pain rating scale used [1]___________________________________________
Purpose: To evaluate the safety and effectiveness of the analgesic(s)
Analgesic(s) prescribed: ____________________________________________
____________________________________________________________________
| Time | Pain | Analgesic
| R | P | BP | Level of
| Other[2] |Plan and |
| |rating
|
| | |
| arousal |
|comments|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
|_____|______|_____________|___|___|____|_________|_________|________|
Source: McCaffery & Beebe, 1989. Used with permission.
Note: May be duplicated for use in clinical practice.
[1] Pain rating: A number of different scales may be used. Indicate
which scale is used and use the same scale each
time.
[2] Possibilities for other columns: bowel function, activities,
nausea and vomiting, and other pain relief measures.
Identify
the side effects of greatest concern to patient,
family,
physician and nurse.
Simple Descriptive Pain Distress Scale [1] None Annoying Uncomfortable Dreadful Horrible Agonizing |___________|___________|____________|__________|___________| | | | | | | 0-10 Numeric Pain Distress Scale [1] No Distressing Unbearable pain pain pain |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| | | | | | | | | | | | 0 1 2 3 4 5 6 7 8 9 10 Visual Analog Scale (VAS) [2] No Unbearable distress distress |___________________________________________________________| | | [1] If used as a graphic rating scale, a 10 cm baseline is recommended [2] A 10-cm baseline is recommended for BAS scales. Source: Acute Pain Management Guideline Panel, 1992.