CHN2617 Adult ICU Pain Orders.pdf - Carondelet
CHN2617 Adult ICU Pain Orders.pdf - Carondelet CHN2617 Adult ICU Pain Orders.pdf - Carondelet
USE BALL POINT PEN – PRESS FIRMLY CARONDELET HEALTH NETWORK HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS ADULT ICU PAIN ORDERS STAT/NOW (Check Box to Left) Critical Care Pain Observation Tool (CPOT) For non-communicative adults in critical care areas 0 1 2 Score Facial Expression Relaxed, neutral; no muscular tension observed Tense; presence of frowning, brow lowering, orbit tightening, and levator contraction Grimacing; all facial movements for 1 plus eyelid tightly closed Body Movement Absence of movements; does not move at all (does not necessarily mean absence of pain) Protection; slow, cautious movements; touching or rubbing site; seeking attention through movement Restlessness; pulling tubes; attempting to sit up or get out of bed; moving limb/thrashing; not following commands; striking out Ventilator Compliance (intubated patients) OR Vocalization Tolerating ventilator or movement; alarms not activated; easy ventilation Talking in normal tone or no sound Coughing but tolerating; alarms stop spontaneously Sighing; moaning Fighting ventilator; asynchrony; blocking ventilation; alarms frequently activated Crying out; sobbing (extubated patients) Muscle Tension (evaluate by passive UE flexion and extension at rest or evaluate when turning patient) Relaxed; no resistance to passive movements Tense, rigid; resistance to passive movements Very tense or rigid; strong resistance to passive movements; inability to complete them Mild: 1-2 Moderate: 3-5 Severe: 6-8 Total: (0-8) Visual Analog Scale (Communicative Adults) Wong-Baker (Non-Communicative Adults) Physician Signature: Date Signed: Time Signed: Physician Printed Name / License # / Telephone #: PATIENT IDENTIFICATION MEC Approval CSJ – 06/30/11 CSM – 06/30/11 CHC – 06/23/11 CHVI – 06/22/11 CHN2617 Expires – 06/2014 Copy 05.02.13 Page 2 of 2 UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED
USE BALL POINT PEN – PRESS FIRMLY<br />
CARONDELET HEALTH NETWORK<br />
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS<br />
ADULT <strong>ICU</strong> PAIN ORDERS<br />
STAT/NOW<br />
(Check Box to Left)<br />
Critical Care <strong>Pain</strong> Observation Tool (CPOT)<br />
For non-communicative adults in critical care areas<br />
0 1 2 Score<br />
Facial Expression<br />
Relaxed, neutral; no<br />
muscular tension<br />
observed<br />
Tense; presence of<br />
frowning, brow lowering,<br />
orbit tightening, and<br />
levator contraction<br />
Grimacing; all facial<br />
movements for 1 plus<br />
eyelid tightly closed<br />
Body Movement<br />
Absence of movements;<br />
does not move at all<br />
(does not necessarily<br />
mean absence of pain)<br />
Protection; slow, cautious<br />
movements; touching or<br />
rubbing site; seeking<br />
attention through<br />
movement<br />
Restlessness; pulling<br />
tubes; attempting to sit<br />
up or get out of bed;<br />
moving limb/thrashing;<br />
not following<br />
commands; striking out<br />
Ventilator Compliance<br />
(intubated patients)<br />
OR<br />
Vocalization<br />
Tolerating ventilator or<br />
movement; alarms not<br />
activated; easy<br />
ventilation<br />
Talking in normal tone or<br />
no sound<br />
Coughing but tolerating;<br />
alarms stop spontaneously<br />
Sighing; moaning<br />
Fighting ventilator;<br />
asynchrony; blocking<br />
ventilation; alarms<br />
frequently activated<br />
Crying out; sobbing<br />
(extubated patients)<br />
Muscle Tension (evaluate<br />
by passive UE flexion and<br />
extension at rest or<br />
evaluate when turning<br />
patient)<br />
Relaxed; no resistance<br />
to passive movements<br />
Tense, rigid; resistance to<br />
passive movements<br />
Very tense or rigid;<br />
strong resistance to<br />
passive movements;<br />
inability to complete<br />
them<br />
Mild: 1-2 Moderate: 3-5 Severe: 6-8<br />
Total:<br />
(0-8)<br />
Visual Analog Scale (Communicative <strong>Adult</strong>s)<br />
Wong-Baker (Non-Communicative <strong>Adult</strong>s)<br />
Physician Signature: Date Signed: Time Signed:<br />
Physician Printed Name / License # / Telephone #:<br />
PATIENT IDENTIFICATION<br />
MEC Approval CSJ – 06/30/11 CSM – 06/30/11 CHC – 06/23/11 CHVI – 06/22/11<br />
<strong>CHN2617</strong> Expires – 06/2014<br />
Copy 05.02.13 Page 2 of 2<br />
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED
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