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SAMPLE 7 – Communication Worksheet for Pain Management Orders

Physician:_______________________
Date:_______________________
Pain Assessment for:________________
Pain Diagnosis:_______________________
Location of Pain(s):_______________________

Check the descriptor:

•   aching
•   throbbing
•   shooting
•   stabbing
•   sharp
•   burning
•   gnawing
•   dull
•   tingling
•   tender

Resident’s behaviour:

•   calling out
•   restless
•   resistant to movement
•   not eating
•   pacing
•   rocking
•   not sleeping
•   withdrawn

Intensity (0-10) circle the pain number:
   none    1    2    3    4    5   
   6    7    8    9    10    worst   

Pattern:

•   continuous
•   intermittent
•   new pain
•   old pain

If a new pain, how long has it been present?
_______________________

What makes it better?
_______________________

What makes it worse?
_______________________

Impact on ADL’s:
_______________________

Family support?
_______________________

Resident’s perception of what is causing the pain:
_______________________

Resident’s goal for pain control:(numerical score)
_______________________
(activity) ________________________

Drug, dosage and total number of doses of all analgesic medications in the past 24 hours: (i.e. PRN, breakthrough and routine) (i.e. Tylenol #3®, Morphine [immediate release], MS contin® [long acting].)
_______________________

Drug, dosage and total number of doses of all adjuvant analgesic medications in the past 24 hours: (i.e. PRN, breakthrough and routine) (i.e. Naproxin®, Elavil®, Ativan®, Gravol®, Tylenol® plain)
_______________________

Non-pharmacological interventions tried in the past:
_______________________

Suggestions for changes in management:
New meds/dosages/intervals:
_______________________
discontinue:
_______________________

Orders:
_______________________

Naprosyn is a registered trademark of Syntex, Elavil is a registered trademark of Merck Frosst, Ativan is a registered trademark of Wyeth-Ayerst, Gravol is a registered trademark of Horner, Tylenol is a registered trademark of McNeil Consumer Products.

Reprinted with Permission. Brignell, A. (ed) (2000). Guideline for developing a pain management program. A resource guide for long-term care facilities, 3rd edition.

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