Pain Management Plan

Appendix

D

Pain Management Plan

f0005

PAIN MANAGEMENT PLAN “Pain assessment is considered part of every patient evaluation, regardless of presenting complaint.”

PATIENT ID CARD Date:

Is pain present upon admission?

Pulse rate:

Temperature:

°C/°F

Respiratory rate:

Weight:

lbs/kg

N

Pain on palpation only? Y

Signs of pain (Check all that apply): Behavior: Normal Depressed

Excited

Agitated

Vocalization:

Continuous

Other

None

Y

Department:

Occasional

N

Attitude:

Cause of pain: Descriptors (Circle):

Posture:

Normal

Frozen

Rigid

Gait:

Sound

Lame weight bearing

Hunched

Guarding

Recumbent

Lame non-weight bearing

Other signs of pain:

Aggressive

Reluctant to move Non-ambulatory

Previous analgesic history:

Restless

Fearful

Agitated

Obtund

Trembling

Inappetant

Nervous

Biting or licking area

Anatomical location of pain (Circle):

Classification of pain (Check): Acute Acute recurrent Chronic (weeks) Chronic progressive

Ventral

Comments:

Dorsal Left

Superficial Deep Visceral Inflammatory Neuropathic Both (Infl/neuro) Cancer

Right

Diagnosis:

Primary hyperalgesia Secondary hyperalgesia Central analgesia

VISUAL ANALOG SCALE

SEVERITY OF PAIN:

No Pain

Indicate event(s) on VAS: Initial/date

Event: 1 2 3 4

Time (HH:MM):

Worst Possible Pain

Date:

PAIN THERAPY (Pharmacologic and complementary) Current

Comments:

Date:

Dose/Route:

Efficacy/Duration:

Comments:

ADDITIONAL THERAPY Surgery Chemotherapy Radiation

Prescribed

Physical therapy

VISUAL ANALOG SCALE

RESPONSE TO THERAPY: Indicate event(s) on VAS

Event: 1 2 3 4 Clinician:

No Analgesia

Time (HH:MM):

Date:

Complete Analgesia

Comments:

Release date: