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Medical/nursing staff will assign a pain scale rating only if the patient is unable to report their pain based on facial grimacing, body language, vocalizations, etc
If the patient reports an adverse change in pain, a more detailed assessment by an RN of the acute and/or chronic pain will be done and may include the following data:
Location of pain. If more than one location they are assessed separately.
Type, quality/description, and patterns of radiation (if applicable)
Alleviating and aggravating factors
Intensity Rating (visual analog or FLACC scale)
Patient’s acceptable rating of pain and pain management history
Current medications for pain and what works best
Alternative methods of pain control used
Vital signs and level of consciousness
Patient’s emotional and behavioral expressions of pain
Level of influence of pain on ADLs
For the patient undergoing moderate sedation or anesthesia, pain assessment and intervention should begin when the patient shows behavioral expressions or verbal expressions of pain.
Pain is monitored throughout each shift.
Pain is evaluated at the onset, and throughout each shift and addressed accordingly; abnormal findings are reported by an LPN to the RN.
A numerical intensity rating of pain is assessed with every set of vital signs, within one hour of an intervention for pain, and if the patient spontaneously reports pain.
If no pain is present, the licensed healthcare provider will monitor for pain as warranted by patient condition, throughout the shift with the pain scale, when the patient complains of pain, and post invasive procedure.
Interventions must be documented when the intensity rating is greater than the patient’s stated acceptable level of pain. Pain intensity rating is re-evaluated and documented within 1 hour after each intervention until the intensity rating is 4 or less or the patient’s stated level of acceptable pain.
Changes from the initial comprehensive assessment of pain should be documented as they occur.
Pain intensity rating is obtained, along with appropriate interventions as needed, 30 minutes prior to physical therapy or activity to optimize performance.
When a patient experiences painful procedures and interventions, pain is treated, interventions documented, along with reevaluation within 1 hour of the intervention.
Prior to transfer of patient, and prior to discharge, pain is reevaluated and treated accordingly. A written or verbal report on pain will be communicated upon transfer of care.
Effectiveness of an intervention should be based upon the route and onset of action of the drug administered; for example, IV opioids are evaluated in 15–30 minutes, whereas oral opioids and non opioids are evaluated 45–60 minutes after administration, or upon discharge if not a new medication.
The physician is notified of the patient’s pain when pharmacologic and non-pharmacologic treatment modalities have been exhausted in reducing the pain to a level acceptable to the patient.
Documentation of pain for all patients, should include the following
Type, description, location, timing of pain
Level of consciousness
Interventions: Pharmacologic & Non-Pharmacologic along with side effects