PAIN RE-ASSESSMENT & MANAGEMENT BY ATTENDING NURSE AND

PHYSICIAN
DATE &
TIME
PAIN
LOCATION
ONSET

Sudden
Gradual

Sudden
Gradual

Sudden
Gradual

Sudden
Gradual

Sudden
Gradual

Sudden
Gradual

Continuous
Intermittent

Continuous

Intermittent

Continuous

Intermittent

Continuous

Intermittent

Continuous

Intermittent

Continuous

Intermittent

At rest:

On activity:

At rest:
..
On activity:
.

At rest:

On activity:
.

At rest:
.
On activity:
.

At rest:
..
On activity:
..

At rest:
..
On activity:

DURATION
FREQUENCY

QUALITY OF
PAIN

PAIN SCORE
PAIN SCALE
USED
ASSOCIATED
SYMPTOMS
INTERVENTIO
N
DRUG/NONDRUG
+ SIDE
EFFECTS

COMMENTS

ASSESSED BY
ATTENDING
NURSE/PHYSI
CIAN

INSTRUCTIONS:
PAIN RE-ASSESSMENT SECTION MUST BE COMPLETED;
A. Re-assess and intervene if pain score is 3 at rest and 4 on activity , or if the pain level is
unacceptable to the patient.
B. Following administration of analgesics:

Within 15 minutes of administration of IV and 30 minutes for IM Analgesics (5 minutes for IV Fentanyl)

Within one hour of administration of oral or rectal analgesics.

The vital signs at each reassessment shall be documented in the file.

C. Then re-assess the pain every 2-4 hours, depending upon the severity and intervene if necessary.
D. If PAIN SCORE is 2 for 24 hours then, re-assessment at the beginning of each shifts (8 hourly).
E. These are only guidelines and the frequency of re-assessment & intervention should change according to clinical
assessment and patient satisfaction.

Pain Re-assessment & Mgt

KAASH 05/028-00

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CRITICAL CARE PAIN OBSERVATION TOOL - 2006

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CRITICAL CARE PAIN OBSERVATION TOOL - 2006

C
INDICATOR

FACIAL EXPRESSION

BODY MOVEMENTS

DESCRIPTION

Relaxed, neutral

Presence of frowning, brow lowering,

orbit tightening and levator
contraction.

Tense
1

All of the above facial movements plus

eyelid tightly closed.
Does not move at all (does not
necessarily mean absence of pain)

Grimacing
2
Absence of movements

Slow cautious movements, touching or

rubbing the pain site, seeking attention
through movements.

Protection
1

Pulling tube, attempting to sit up,

moving limbs/thrashing, not following
commands, striking at staff, trying to
climb out of bed.
No resistance to passive movements
MUSCLE TENSION
Evaluation by passive flexion
And extension of upper extremities
COMPLIANCE WITH THE
VENTILATOR
(intubated patients)
OR
VOCALIZATION
(Extubated Patients)

SCORE

No muscular tension observed

Resistance to massive movements

Strong resistance to passive
movements, inability to complete them
Alarms not activated, easy ventilation
Alarm stops spontaneously
Asynchrony: blocking ventilation,
alarms frequently activated
Talking in normal tone or no sound
Sighing, moaning
Crying out, sobbing

Restlessness

Relaxed
0
Tense, rigid
1
Very tense or rigid
2
Tolerating ventilator or movement
0
Coughing but tolerating
1
Fighting ventilator
2
Talking in normal tone or no sound
0
Sighing , moaning
1
Crying out, sobbing
2

TOTAL, RANGE
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