ADULT PAIN ASSESSMENT/DOCUMENTATION/REASSESSMENT/ DOCUMENTATION.

Assessment for PHYSICAL pain,SURGICAL pain ,and NONSURGICAL pain.

Assessment for pain Q4hours prn pain or more frequent .For po medications such as percocet,norco,lortab,oxycodone,hydrocodone & acetaminophen, tramadol, advil,Ibuprofen,assess before giving medication and document, reassess after one hour (1hour)of giving the medication and document immediately.

The intravenous medications given such as morphine sulfate, dilaudid (hydomorphine ),Toradol, assessment before giving medication, reassess 30minutes after giving the medication and document. Documentation is very important. If you did not document the assumption is that it was not given.

There are verbal Standard Pain Scale in which the person can rate their pain level on a scale of 0 to 10.

1 to 3 is mild pain.

4 to 6 is moderate pain.

7 to 9 is really bad pain,very severe.

And 10 is the worst pain ever.

And there are the “Pain Faces Scale”.0 means no hurt and 10 means hurts a lot.

Assess your patient constantly for pain or discomfort. Remember that your patients and family members are your customers, and pain is SUBJECTIVE. Your assessment is OBJECTIVES FINDING such grimace, crying ,moaning. But if your patient said that his pain is 10 it is 10.Choose the appropriate medication to give to your patient.Medicate on time and encourage your patient to call for help, to use incentive Spirometry if indicated and to take a deep breath. Encourage ambulation if not contrainicated.Empower your patient to take charge of their own health. Show that you care.

SOME CHEAT SHEET THAT CAN HELP WHEN IT COMES TO PAIN MEDICATION.

1.Assess every patient under your care for pain,new admissions, current patients and document your findings.Gather information which is data collection. Planning:

What do you plan to do about your patient pain?.

What is your intervention?.

For example intervention with po medication or iv medication?.Call the doctor if medications are not working properly. Evaluation of plan and documentation.

2. Educate patient on pain medications. Ask patients to call you at the initial stage of their pain and do not wait for the pain to get worst. 3.Document, reassess, document, reassess and document. Is the pain medication effective?.If it is not effective what is the next action to take?.Did you notify the doctor?.

Which doctor should you call?.

The primary care physician or the physician on call?.

What is the intervention?.

What is the next plan of action?.

What is implemented?.

Is the intervention working for your patient?.

What are the side effects of Narcotics?.

1. Overdose of medications. Narcan ( naloxone is the drug use for opioid overdose)

2.Constipation.( Stool softener such as Colace or doculax can help)

3.Upset stomach.

4.Nausea and Vomiting.(Phenergan 12.5mg, Zofran 4mg IV,Compazine, Reglan, Anzemet)

5. Sedation can result from too much medication. Decrease the amount of medication given. Call and notify the doctor. Space out the interval ,Q6hours prn instead of Q4hours prn pain per doctor order .

6.Itching.Medications such as dilaudid,tramadol or morphine can make your patient itch.(Benadryl 25mg or 50mg po or IV)

7.Hallucination.Some patients after taking morphine can be fighting elephants 🐘 or beating up tigers 🐅Assess your patient systematically,monitor and document.

Do not forget to use two patient identifiers to identify patient before giving medication. This is one of the National Patient Safety Goals on medication administration.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: