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Nursing: Universal Protocol and Skills Update, Medicine, Page 135

Nursing: Universal Protocol and Skills Update

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Documentation in the
Nurses Notes.
 When charting pain levels and characteristics, describe the location of the pain and
note if it's internal, external, localized, or diffuse. Record whether the pain interferes
with the patient's sleep or activities of daily living. In the chart describe what the
pain, feels like in the patient's own words. Chart the patient's description of how long
the pain lasts and how often it occurs. Record the patient's ranking of his pain using
a pain rating scale.
 Describe the patient's body language and behaviors associated with pain, such as
wincing, grimacing, or restlessness. Note sympathetic responses commonly
associated with mild to moderate pain, such as pallor, elevated blood pressure,
dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis.
Record parasympathetic responses commonly associated with severe, deep pain,
including pallor, decreased blood pressure, bradycardia, nausea and vomiting,
dizziness, and loss of consciousness.
 Chart situations that worsen the pain as well as interventions that relieve or
decrease the pain, including heat, cold, massage, or drugs.
 Document interventions taken to alleviate your patient's pain and the patient's
responses to these interventions. Also, note patient teaching and emotional support
provided.