ask patient to rank pain:
- Adults on scale of 0-10, or a visual analog scale
- child of 3 or older use the faces 0-5 or visual analog
- 2 months to 3 years use the FLACC
- observing behavior indicative of pain
assess patient's pain location by asking the patient to point to the location of the pain
- if the patient is unable to verbalize or communicate location observe
- pulling on ear
- limping
- rubbing an area
assess the quality of the pain by asking the patient the characteristics of the pain
- sharp
- dull
- stabbing
- aching
- throbbing
assess the duration of pain by asking the patient:
- how long does the pain last
- how often does it occur
- how long have you experienced this pain
provide three of the following pain relief measures
- repositions the patient or assists the patient to a different position
- gives the patient a back
- uses relaxation and/or distraction techniques
- guided imagery
- watching TV
- drawing a picture or coloring
- engage in conversation about a happy memory or hobby
- pacifier
- cuddling
- play
- singing
- applies heat or cold when assigned
- administer pain med when assigned, or
- if not assigned request the primary nurse to administer pain med
reassess the patient's pain by:
- asking the adult patient to rate the pain on a scale of 0-10 or visual analog scale
- asking the child of 3 or older to rate the pain on a 0-5 Faces scale or visual analog scale
- using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age
- observing behavior indicative of pain in an infant or noncommunicating- adult or child
- moaning,
- grimacing
- clutching
- restlessness
Records:
- level of pain
- location of pain
- intensity of pain
- duration of pain
- characteristics of pain
- predisposing factors
- aggravating factors
- measures to relieve pain
- patients response to measures to relieve pain
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