Patient Name                        Provider Name                                   Room #       MR#             
Date Time Pain Behaviors § Activity Level * Medication Time Pain Behaviors after 1-2 hr § Arousal Level after 1-2 hr + Non-Drug Therapy ^ Initial
                   
                   
                   
                   

§ Behavior Examples: Resists getting out of bed, groans, grimaces, appears agitated, irritable, tearful

* Activity Level: A = Ambulatory, B = Bed, WC = Up in Wheelchair, BR = Up to Bathroom, M = meal, C = Chair, R = ROM

+ Level of Arousal: 0 = Fully awake, 1 = Relaxed, 2 = Drowsy, 3 = Difficult to arouse, 4 = Stuporous, 5 = Semi -Comatose

^ Non-Drug Interventions: 1 = repositioning, 2 = Dim Light/Quiet Environment, 3 = hot/cold Application, 4 = Distractions, 5 = Music, 6 = Massage, 7 = Other

 

Adapted from Pain Management Algorithm Resource Manual

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