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Staffing Analyzer: Simplifying Data for Nurse Managers 60 Essential Forms for Long-Term Care Documentation

Nursing responsibilities for assessing, managing, and evaluating effectiveness of pain management include the following:

• Determining the nature of the pain and its impact on the resident
• Identifying factors that affect the resident's perception and expression of pain
• Determining when to administer analgesics
• Deciding which analgesic to administer, if more than one is ordered
• Determining the dose of analgesic medication to administer, if a range is prescribed
• Evaluating the effectiveness of the analgesic
• Assessing for and managing side effects of the medication
• Determining why the analgesic was ineffective, if applicable
• Determining the need to change the dose, timing, or medication and reporting this information to the healthcare provider
• Using nursing interventions to promote comfort and relieve pain
• Making sure the plan of care describes pain assessment and management
• Documenting pain assessment and intervention noted herein to relfect use of the nursing process

This week's tip is from Clinical Documentation: An Essential Guide for Long-Term Care Nurses.