Initial Pain Assessment Tool Form PDF Details

The Initial Pain Assessment Tool is a comprehensive form designed to help healthcare professionals understand a patient's pain. As of its latest version, this tool captures critical elements such as the pain's location, intensity, and characteristics, providing a structured way for patients to convey their experiences. It requests the patient or nurse to mark the pain's location on a drawing and rate its intensity using a specified scale. Detailed questions delve into whether the pain is constant or intermittent, and if the latter, how often it occurs. The quality of the pain is described in the patient's own words, allowing for a nuanced understanding of its nature. Additionally, the form explores the onset, duration, variations, and rhythm of the pain, how the patient expresses this discomfort, what relieves or exacerbates it, and its overall effects on the patient's life, including their sleep, appetite, physical activity, relationships, emotions, and concentration. Finally, there is space for any other comments and a plan of action. This tool, copyrighted by Pasero and McCaffery in 2008, is not just a form but a bridge between patient and healthcare provider, ensuring that pain, a complex and subjective experience, is systematically assessed and managed.

QuestionAnswer
Form NameInitial Pain Assessment Tool Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespain assessment, initial pain assessment tool, initial pain assessment form, form initial pain

Form Preview Example

FORM 1.1 INITIAL PAIN ASSESSMENT TOOL

Date ______________

Patient’s Name _______________________________________________________Age _________ Room ____________

Diagnosis__________________________________________ Physician______________________________________

Nurse ______________________________________

1. LOCATION: Patient or nurse mark drawing.

2.INTENSITY: Patient rates the pain. Scale used____________________________________________________________

Present pain: ________ Worst pain gets: _________ Best pain gets: __________ Acceptable level of pain: __________

3.IS THIS PAIN CONSTANT? _____ YES; ____ NO IF NOT, HOW OFTEN DOES IT OCCUR? ____________________

4.QUALITY: (For example: ache, deep, sharp, hot, cold, like sensitive skin, sharp, itchy) ________________________

5.ONSET, DURATION, VARIATIONS, RHYTHMS: ___________________________________________________________

_______________________________________________________________________________________________________

6.MANNER OF EXPRESSING PAIN: ______________________________________________________________________

_______________________________________________________________________________________________________

7.WHAT RELIEVES PAIN? _______________________________________________________________________________

_______________________________________________________________________________________________________

8.WHAT CAUSES OR INCREASES THE PAIN? _____________________________________________________________

_______________________________________________________________________________________________________

9.EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea) __________________________________________________________________

Sleep _________________________________________________________________________________________________

Appetite _______________________________________________________________________________________________

Physical activity ________________________________________________________________________________________

Relationship with others (e.g., irritability) ___________________________________________________________________

Emotions (e.g., anger, suicidal, crying) ____________________________________________________________________

Concentration __________________________________________________________________________________________

Other__________________________________________________________________________________________________

10.OTHER COMMENTS: ________________________________________________________________________________

_______________________________________________________________________________________________________

11.PLAN:______________________________________________________________________________________________

_______________________________________________________________________________________________________

May be duplicated for use in clinical practice. Copyright Pasero C, McCaffery M, 2008. As appears in Pasero C, McCaffery M. Pain: Assessment and pharmacologic management, 2011, Mosby, Inc.

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This document will require you to enter specific information; in order to guarantee correctness, you should adhere to the guidelines listed below:

1. It's important to fill out the pain assessment forms properly, thus be attentive while filling out the segments containing all these fields:

Completing part 1 in universal pain assessment tool pdf

2. The third step would be to fill out these particular blanks: INTENSITY Patient rates the pain, Present pain Worst pain gets, IS THIS PAIN CONSTANT YES NO IF, QUALITY For example ache deep, ONSET DURATION VARIATIONS RHYTHMS, MANNER OF EXPRESSING PAIN, WHAT RELIEVES PAIN, WHAT CAUSES OR INCREASES THE PAIN, EFFECTS OF PAIN Note decreased, Accompanying symptoms eg nausea, and Sleep.

Writing segment 2 in universal pain assessment tool pdf

It is easy to make an error while filling in your WHAT CAUSES OR INCREASES THE PAIN, consequently make sure to take another look before you send it in.

3. In this part, look at Sleep, Appetite, Physical activity, Relationship with others eg, Emotions eg anger suicidal crying, Concentration, Other, OTHER COMMENTS, PLAN, and May be duplicated for use in. Each of these are required to be filled in with utmost precision.

Step # 3 in filling out universal pain assessment tool pdf

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