Pain Evaluation Pain Evaluation Step 1 of 3 33% X/TwitterThis field is for validation purposes and should be left unchanged.Select Patient-- Select Patient --Patient Full NamePatient Name First Middle Last Date MM slash DD slash YYYY Does the resident have any diagnosis which would give reason to believe the patient would be in pain?NoYesDescribe cause, origin of pain, radiation of pain, and prior treatment:Ask resident: Have you had pain or hurting at any time in the last 5 days?NoYesSelect 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 Stabbing Sharp Cramping Hot/Burning Tingling Other Additional symptoms associated with pain (e.g nausea, anxiety:)Pain is increased by (describe circumstances or activities):Any language and/or cultural barriers:NoYesIf Yes, ExplainTimes 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 a resident is able to interview, use Wong-Baker, if not use PAINAD (CODE: I=internal E=External A=Acute C=Chronic)Site ASite BSite CSite DAsk resident: “Rate the intensity of your worst paint over the last 5 days, with 0 being no pain and 10 as the worst pain you can imagine”Ask the resident: “How much of the time have you experienced pain or hurting over the last 5 days?”At PresentSite ASite BSite CSite D1 hour after medicationSite ASite BSite CSite D3 Hours after medicationSite ASite BSite CSite DWorse it getsSite ASite BSite CSite DBest it getsSite ASite BSite CSite D PAINADBreathing independent of vocalization 01Occasionally labored breathing. Short of hyperventilation2Noisy labored breathing. long period of hyperventilation. Cheyne-Stokes respirationScoreNegative Vocalization 012ScoreFacial Expression 012ScoreBody Language012ScoreControllability012Score Has the resident had any of the following changes in their daily activities or habits? Select observed changes Participation in activities Inability to perform ADL Insomnia 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/ (eg. anger,crying, depressed) Loss of appetite other sleep disturbances Nonverbal/noncognitive signs of pain: Check Y (Yes) or N (No) for each of the following nonverbal/noncognitive signs which could indicate the presence of pain. (Select one will be considered as blank)Facial Expression: ( select yes or no)Grimacing/Distored faceNoYesClenched jaw or teethNoYesFrowny/ScowlingNoYesTightly shut lipsNoYesGlazed eyes / tearingNoYesWrinkled browsNoYesTurned down mouthNoYesFrightNoYesVocalization: ( select yes or no)MoaningNoYesGruntingNoYesGaspingNoYesCrying/WhimperingNoYesScreamingNoYesCursingNoYesBody actions/observed behaviorThrashing/Rocking No Yes Pounding No Yes Biting No Yes Palior No Yes Threatening guestures No Yes Rubbing body parts No Yes Altered Gait, posture/limping No Yes Strenous or altered breathing No Yes Increased vital signs No Yes Knees pulled up into abdomen No Yes Fidgeting/Irritability No Yes Pacing No Yes Perspiration No Yes Clenched Fists No Yes Wringing of hands No Yes Increased hand finger movements No Yes Striking out at others No Yes Depressed mood No Yes Pain is relieved by (check all that apply):check all that apply Medication Deep relaxation Frequent position Heat Check all that apply Cold Massage Meditation Music Check all that apply Visual imagery Enemas Diversional activity Distraction Check all that apply None of the above Other (plese specify other below) Specify other if box was checkedAny adverse consequences of interventionNoYesExplain the adverse consequences of interventionIs the resident on a scheduled pain regimen?NoYesWhat is the pain medication in use by the resident?Does the resident receive PRN medication?NoYesEnter PRN MedicationIs pain medication effectiveNoYesTime elapsed until pain relief:Conclusion No pain, intervention is not necessary. Reasses 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: Enter notes, comments or observationsRegistered Nurse Name First Last Registered Nurse SignatureDate MM slash DD slash YYYY Client representative name First Last Client/Representtive SignatureDate MM slash DD slash YYYY