Source of Information: ST.

FRANCIS REGIONAL MEDICAL CENTER

Patient ¡ WICHITA, KANSAS
Child â
Parent G
Nurse ê

PAIN FLOW SHEET

Date/Time Location of Pain Pain Pharmacologic/ Mode of Source of Information BP P R Side Effects/ Evaluation of Intervention/s Initials
Rating Nonpharmacologic Administration LOC Response/Comments
0-10

Signature Initials Signature Initials Signature Initials

Mode of Administration Side Effects Mental Status

EPCA ESQ ENausea/Vomiting EAlert EOriented x3 EDisoriented EConfused EIncomprehensible Sounds
EIV EPO EResp Depression ELethargic (Drowsy but when stimulated obeys simple commands)
EIM EPatch EPruritis ESemicomotose (Purposeful movements when stimulated. Doesn’t obey
EEpidural EUrinary Retention commands or answer questions. Doesn’t talk at all.)
EAltered Mental Status EComa (Decoritcate: Draws hands up onto chest when stimulated, but
not purposefully.)
Nonpharmacologic Pediatrics Pediatrics only (1-10 scale)
Interventions
ECold EImagery EHolding A. Verbal/Vocal B. Body Movement C. Facial D. Touching (localizing
pain)
EDistractions EMassage ERocking 1 = positive 1 = moves easily 1 = smiling 1 = no touching
EEnvironmental EMusic EPacifier 2 = other complaint, 2 = neutral shifting 2 = neutral 2 = reaching, patting
Control EPositioning ESecurity object whimper
3 = pain, crying 3 = tense, flailing 3 = frown, grimace 3 = grabbing
EExercises ERelaxation arms & legs
EHeat ETENS 4 = screaming 4 = clenched teeth