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Schedule Consultation
Pain Evaluation
Pain Evaluation
Step
1
of
6
16%
General Information
Does this resident have any diagnosis(es) which would give reason to believe he/she would be in pain?:
Yes
No
If yes, describe cause, origin of pain, and prior treatment:
Ask resident: "Have you had pain or hurting at any time in the last 5 days?":
Yes
No
If yes, date of pain onset:
MM slash DD slash YYYY
As the patient describes it, what does the pain feel like? (check all that apply.):
Aching
Heavy
Tender
Splitting
Tiring
Exhausting
Throbbing
Shooting
Stabing
Sharp
Cramping
Hot/Burning
Tingling
Other
Please specify:
Additional symptoms associated with pain (e.g., nausea, anxiety):
Pain is increased by (describe circumstances or activities):
Any language and/or cultural barriers:
Yes
No
If yes, explain:
Time when pain is worse:
Early morning (pre-dawn)
Morning
Afternoon
Evening
Night
Pain Location/Type/Frequency/Intensity/Duration
If the resident is able, identify pain type(s) and locations and record below. Label sites as A, B, C, D. Code pain type, frequency and intensity/duration as applicable. If resident is able to interview, use Wong-Baker, if not, use PAINAD.
TYPE
Code: I = Internal; E= External
Code: A = Acute; C = Chronic
SITE A
SITE B
SITE C
SITE D
Wong Baker
Ask resident: "Please rate the intensity of your worst pain over the last 5 days, with 0 being no pain and 10 as the worst pain you can imagine"
At Present
SITE A
SITE B
SITE C
SITE D
1 Hour after Medication
SITE A
SITE B
SITE C
SITE D
3 Hours after Medication
SITE A
SITE B
SITE C
SITE D
Worst It Gets
SITE A
SITE B
SITE C
SITE D
Best It Gets
SITE A
SITE B
SITE C
SITE D
Frequency
Ask resident: "
How much of the time have you experienced pain or hurting
over the last 5 days?"
1. Almost constantly
2. Frequently
3. Occasionally
4. Rarely
9. Unable to answer
SITE A
SITE B
SITE C
SITE D
PAINAD: Score each row and total
Breathing (Independent of Vocalization)
0. Normal
1. Occasional labored breathing. Short period of hyperventilation.
2. Noisy labored breathing. Long period of hyperventilation. Cheyne Stokes respirations.
Negative Vocalization
0. None
1. Occasional moan or groan. Low level speech with a negative or disapproving quality.
2. Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial Expression
0. Smiling or inexpressive
1. Sad, frightened, Frowning
2. Facial grimacing
Body Language
0. Relaxed
1. Tense, Distressed pacing, Fidgeting
2. Rigid, Fists clenched, Knees pulled up. Pulling or pushing away. Striking out.
Consolability
0. No need to console
1. Distracted or reassured by voice or touch
2. Unable to console, distract or reassure.
Pain Effect on Function
Has the resident had any of the following changes in daily activities or habits?
Inability to perform ADLs
Insomnia
Other sleep disturbances
Loss of appetite/weight loss
Constipation
Incontinence
Decreased ability to concentrate
Withdrawal from activities or relationships
Ability to focus, concentrate
Decrease/increase in physical/social activity
Changes in mood/emotions (e.g., anger, crying, depressed, etc.
Non Verbal/Non Cognitive Signs of Pain
Check Yes or No for each of the following non verbal/non cognitive signs which could indicate the presence of pain.
Facial Expressions
Grimacing/distorted face
Yes
No
Clenched Jaw/Teeth
Yes
No
Frowning/scowling
Yes
No
Tightly shut lips
Yes
No
Glazed eyes/tearing
Yes
No
Wrinkled brow
Yes
No
Turned down mouth
Yes
No
Fright
Yes
No
Vocalizations
Moaning
Yes
No
Grunting
Yes
No
Gasping
Yes
No
Crying/Whimpering
Yes
No
Screaming
Yes
No
Cursing
Yes
No
Body Actions/Observed Behaviors
Thrashing/rocking
Yes
No
Pounding
Yes
No
Biting
Yes
No
Pallor
Yes
No
Threatening gstures
Yes
No
Rubbing body parts
Yes
No
Altered gait/posture/limping
Yes
No
Strenuous or altered breathing
Yes
No
Increased vital signs
Yes
No
Knees pulled up into abdomens
Yes
No
Fidgeting/irritability
Yes
No
Pacing
Yes
No
Perspiration
Yes
No
Clenched fists
Yes
No
Wringing of hands
Yes
No
Increased hand/finger movements
Yes
No
Striking out at others
Yes
No
Depressed mood
Yes
No
Relief of Pain
Pain is relief by (check all that apply)
Medication
Deep Relaxation
Frequent Position Changes
Heat
Cold
Massage
Meditation
Music
Visual Imagery
Enemas
Diversional Activity
Distraction
None of the above
Other
Other, please specify:
Any adverse consequences of interventions?
Yes
No
If yes, Explain:
What is the resident's acceptable pain of level
Is the resident on a scheduled pain regimen?
Yes
No
If yes, pain medication(s) in use:
Does the resident receive a PRN medication?
Yes
No
If yes, pain medication(s) in use:
Is pain medication effective
Yes
No
Time elapsed until pain relief:
Conclusion
Choose the following:
No pain, intervention is not necessary. Re-access quarterly or with onset of pain
Pain management intervention is necessary, refer to resident plan of care.
Change in intervention, refer to resident plan of care.
Interdisciplinary Team (IDT) Progress Note:
Name of Patient
Attending Physician
Date:
MM slash DD slash YYYY
Signature of Physician:
Comments
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