PDF file - American Nephrology Nurses Association
PDF file - American Nephrology Nurses Association
PDF file - American Nephrology Nurses Association
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F6. Assistive devices: None Cane/Crutch Walker Manual wheelchair<br />
Electric wheelchair Limb prosthesis<br />
F7. Postural hypotension:<br />
F8. Do you have strategies for avoiding falls? Yes No<br />
Explanation:<br />
F9. Patient risk for fall: low moderate high<br />
Pain Assessment<br />
Complete for each assessment<br />
P1. Frequency of pain Intensity of pain<br />
No pain<br />
Mild<br />
Pain daily<br />
Moderate<br />
Pain every other day<br />
Times when pain is excruciating<br />
Pain weekly<br />
Pain monthly<br />
Pain related only to a specific activity:<br />
P2. Location of pain:<br />
Character of pain: throbbing burning stabbing aching<br />
How long ago did you start experiencing this type of pain?<br />
Worst pain you ever had:<br />
P3. Intensity of pain on a scale from 1-10 with 10 the worst pain you ever experienced:<br />
P4. How much does pain affect your life?<br />
What do you do to decrease/eliminate pain?<br />
What makes the pain worse?<br />
P5. Are you taking medications for pain? Yes No<br />
If yes, what medications:<br />
Does the medication provide relief? Yes No<br />
What side effects do you experience?<br />
Do you have other strategies for dealing with pain?<br />
How do you respond to pain (i.e., cry out, moan, become withdrawn or angry, etc.)?<br />
Comprehensive Interdisciplinary Patient Assessment / ANNA & NKF Version: 11/18/08 18
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