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Nonverbal Pain Indicators (CNPI) Cheat Sheet by

Pain Eval; Patient cannot be Interviewed
assessment     emr     pain     non-interviewable

Introd­uction

Evaluation form to determine if a patien­t/r­esident is experi­encing pain where they are not able to effect­ively commun­icate with the caregiver. We observe the signs that are usually present when a person is experi­encing pain. Patients with dementia or severe medical conditions are often not able to commun­icate intell­igently with caregivers or others.

Checklist of Nonverbal Pain Indicators (CNPI)

Indi­cator
Deta­ils
With Movement
At Rest
Agitation
 
Body Positioning
 
Facial Grimac­es/­Winces
Furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expres­sions
Restle­ssness
Constant or interm­ittent shifting of position, rocking, interm­ittent or constant hand motions, inability to keep still
Rubbing
Massaging affected area
Vocal compla­ints: Non-verbal
Sighs, gasps, moans, groans, cries
Vocal compla­ints; Verbal
Words expressing discomfort or pain [e.g., ouch," "that hurts"]; cursing during movement; exclam­ations of protest [e.g., "­sto­p," "­that's enough­"
Scoring:
Score a 0 if the behavior was not observed. Score a 1 if the behavior occurred even briefly during activity or at rest. The total number of indicators is summed for the behaviors observed at rest, with movement, and overall. There are no clear cutoff scores to indicate severity of pain; instead, the presence of any of the behaviors may be indicative of pain, warranting further invest­iga­tion, treatment, and monitoring by the practi­tioner.

Suspected Cause

Describe: ______­___­___­___­___­___­___­___­___­___­___­___­___­___­_______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
 

Pain Management

Medications (Type, Dosage & Frequency)
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
Others indicate all modali­ties:
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______
______­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­___­______

Effect­iveness

  Partial   Complete   None

Care Planning

1. Continue current pain Med(s)
 Yes No
2. Refer to Physician for:
 Medication Evaluation
 Rehabilitation Evaluation
 Exacabarating factors
 Alleviating factors
3. OOB Schedule Adjusted (Out of Bed)
 Yes No
4. Other: ______­___­___­___­___­___­___­___­___­___­___­___­___­___­______

Tips for docume­ntation

Asse­ssm­ent
Intensity (pain scale scores or other findings)
Onset
Intens­itity, Locati­on(s)
Duration / Frequency
Interm­ittent vs Continuous / Pattern
Diurnal variation (effect of the time of day)
Precip­itating / Allevi­ating factors
Radiation
Referral
Associated symptoms
Effect on functi­on/­daily activities
Goals for pain management
Inte­rve­nti­ons
Non-ph­arm­aco­logical
Pharma­col­ogical (drugs)
Patient’s response
Eval­uat­ion­/Re­ass­ess­ment
Assessment findings post interv­ention
Any need for changes in pain management plan

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