Pain Flow Sheet: Cognitively Impaired
| 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