comprehensive pain assessment form — cognitively intact

Pain Management Interdisciplinary Team SummaryPhysician and IDT should discuss physician’s findings and develop interventionsP roblem related to: D efining Characteristic sG oal sIntervention s( check those that apply)check those that apply )( check those that apply )Responsible( ( check those that apply )Disciplin eC hronic physicalResident self report o f Resident will:5 th vital sign monitoring Collaborate with physician /Verbalize or acknowledge pain C omplete pain assessment PA-C/NP if pain contro ld isabilitypain, discomfort, fatigu ewhen questioned by staffM onitor elements of pain: measures currently ordere dC hronic psychological O bserved non-verba lIndicate location of pain whenF requenc yare ineffectiv ed isabilityb ehavior cues of pai n questioned by staffI ntensit yTeach, coach, and monito rM usculoskeletalP hysical and socialEstablish a pain goal of tolerabl eL ocatio nadjuvant therapy (distractio nS tandardized pain scale imagery, relaxation )impairmentw ithdrawa llimits on a standardized pai nu sedDocument pain ratin gC irculatory impairment A ltered ability to continu e scaleA ssess resident 20-3 0before/after intervention sS kin or tissue impair-previous activitie sA lert staff of need for PRNm inutes after medicatio n Monitor sleep pattern, adjus ta nalgesic to maintain comfortm entAnorexi aa dministration fo rmedications and non -E xpress relief or decreasede ffectivenes smedication interventions t oN eurological impairment W eight change sd iscomfort 20-30 minutes afte r R ecord response t oallow 3-4 hour sA dvanced diseaseC hanges in slee pa nalgesic us em edications and adjus t uninterrupted slee pp rocesspatternsAlert staff of need for non-m edication as necessar y Assess GI status an dA geFacial mask of pai nmedication interventions toOffer support and reassur-tolerance to medications;improve/maintain comforta nce that pain relief will be implement bowel program t oD iagnosis/medicalG uarded movemen tReport or exhibit increased ROM p rovided quickly and to th e prevent constipatio nh istory of: ( circle th e L imited range of motio n20-30 minutes after analgesic use m aximum extent possibl e Assess changes in pain tha tc orrect Dx/Hx)L imited ability to perfor mE ducate resident/significant may indicate new proble mDemonstrate muscle relaxatio nD iabetesA DL so thers about pain/pain re-1:1 visits to provid ewhen experiencing increase dliefmeasurestherapeutic interventio nA SHD ( Arteriosclerotic Hear t L imited ability to transfe r discomfortU tilize pain managemen t 1:1 visits to encourag eD isease)a nd ambulateVerbalize frustrations & feeling s f low shee tspiritual resource sP VD ( Peripheral Vascular Disease )Gait disturbancer egarding disease proces sT each and perform non - Volunteer visit sArthritisE xpress loss of intimacy andm edication intervention s 1:1 visits to identify foo dFallsHip Fracturec ompanionshipa nd evaluate effect (circl e preferences and comfor tD econditioningP articipate in activity programs o r t hose that apply )food sOsteoporosisS low rehabilitationleisure activitiesP ositionin gInvolve family in initial pai nP athological Bone FxCognitive dysfunction Have 3-4 hours of uninterrupted M assag eassessmen tO ther Fracturessleep at nightC old/hea tDocument historica l(impaired memory)M ultiple SclerosisWill have decreased or resolve d R elaxationbehavior to express pai nI ncontinenceindicators of discomfort (crying,D iversio nAround the clock (ATC )DepressionC onstipationExerciseacting out, restlessness,dosing of medication sO ther: _____________D eep breathin ginsomnia, etc.)Medicate before planne dT ENSactivities/exercise sMusicElevation of extremitiesImmobilizationD ate I nitial s S ignature/Titl eI nitial s Signature/Titl eR NS = Nursing Service sESPONSIBLE DISCIPLINESC H = ChaplainPT = Physical Therap yD ate I nitials S ignature/Titl eI nitial s Signature/Titl eDT = Dietar yST = Speech TherapyPR = Physician/Mid-Level Practitioner RT = Recreational Therapy/Activities= Occupational TherapySS = Social ServicesResident_____________________ ID# ___________________Room # ____________ Physician ________________________(ora facilitylabelcanbeplacedhere)Provided by the Oklahoma Foundation forMedical Quality, the Medicare QualityImprovement Organization for Oklahoma,under contract with the Centers forMedicare & Medicaid Services, US Dept.of Health and Human Services. Thecontents do not necessarily reflect CMSspolicy. 1A-032-CPACIM-OK-040306.OTFAM = FamilyAugust2001