Manual: Hospice Policy and Procedure Manual (Ver 3) External Reference: JCAHO: PC.2.20, PC.2.160, PC.8.10
This customizable document, Behavioral-Physiological Pain Scale for Non-Verbal or Pre-Verbal Patients, is taken from MCN Healthcare’s Hospice Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools. Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards. Here is some sample content from Behavioral-Physiological Pain Scale for Non-Verbal or Pre-Verbal Patients:
| | BEHAVIORAL-PHYSIOLOGICAL PAIN SCALE FOR
NON-VERBAL OR PRE-VERBAL PATIENTS
Score
Assessment Guideline
No Signs of Irritability or Pain Exhibited
+
Signs of Irritability
Intermittent vocalizations, soft or brief cry but able to suck or feed
Increased activity of extremities, restless, purposeless movements but trunk is relaxed
Frowning, furrowed brow, eyes open
Mildly increased tone of extremities
Increased arousability, more awake than usual
Unexplained mild changes in respiratory pattern, HR and BP
++
Signs of Pain
Loud cry, sustained attempts to cry
Refuses to feed, eat and/or... |
| Second excerpt: |
| | ...tightly
Decreased activity, fatigue, social withdrawal
Tense muscles, guarding, posturing
Flushed face, diaphoresis
Change in sleep or awake pattern
Attempts to withdraw limb from pain or tries to touch hurt area
Unexplained duskiness/decreased oxygen saturations
Unexplained changes in RR, HR and BP
Developed at Fountain Valley Regional Hospital and Medical Center, CA by F Box RN, MJ Wainwright RN and L Thompson RN, rev 3/97
This tool should be used as a guideline for healthcare... |
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