The caregivers and staff will observe the resident and document nonverbal signs, including changes in the resident's face, voice, body, mood and behavior. To treat pain noninvasively, caregivers and support staff may reposition the patient, distract him, change the environment or use a heat pad or ice. Professional Staff - Nursing Assessment protocols. The nursing staff reviews an assessment, as well as the patient's vital signs, history and physical. Nursing also confirms location and type of pain, fills out resident assessment protocol pain sheet with MDS codes.
Medication is adjusted, if necessary, and a referral is made to a physician if appropriate.
During the assessment protocol, a physician performs various duties, including reviewing the resident's chief complaint and history of pain. The physician also takes a general medical and social history, and performs a physical exam. At this stage, the physician will develop a care plan based on the resident's history and physical, along with information provided by the nursing staff on the pain sheet. The plan also may include medical management, procedures, referral to physical therapy or psychology. The physician will promote interdisciplinary team participation and leadership, and conduct medical follow-up visits.