Form 1: Modified Resident's Verbal Pain Inventory (M ... - CareSearch

Module 3 - Clinical Care
Form 1: Modified Resident’s Verbal Pain Inventory (M-RVBPI)
Note: This questionnaire is to be answered at interview
Date:
Time:
Name:
1. Have you had any pain in the last 24 hours?
Prompts: An ache; feeling tender; hurting; feeling stiff and sore;
headache.
Please tick: Yes No
Use the prompts for pain from this item throughout the
questionnaire, as needed
Now bearing in mind the resident’s usual abilities, and to assess
the resident’s pain on movement, please ask the resident to
move in the way that he/she is usually able to move (e.g. walk,
rise to a standing position and then sit down again, turn over in
bed, bend and / or raise their arms and legs, as appropriate)
Please state movement(s) made
2. (a) Did you have any pain when you were moving just now?
Please tick: Yes No
(b) Where was the pain when you were moving?
Show body map.
Location(s)
(c) And how bad was your pain when you were moving, just now?
Please tick:
No Pain Mild Moderate Severe
Note: use the chart showing these response options in large font,
if the individual is able to see them. If the individual reports no
pain using either of these two items, this is the end of the pain
check. Otherwise, please continue
3. Please tell me more about all the pain or pains you have had
in the past 24 hours (show body map). Show me all the places
where the pain is or has been.
List pain sites
4. In the past 24 hours, how bad has the pain been as its worst?
Prompts: most troublesome, when it was as bad as it got.
Please tick:
No Pain Mild Moderate Severe
5. In the past 24 hours, how bad has the pain been at its least?
Prompts: least troublesome or not there at all, when it was as
good as it got.
Please tick:
No Pain Mild Moderate Severe
6. How bad is your pain now?
Please tick:
No Pain Mild Moderate Severe
7. In the past 24 hours, please tell me how much pain has had
an effect on your walking ability (if applicable)?
PLEASE TICK here if the person is unable to walk
(regardless of pain)
Otherwise, please tick below:
No effect Mild
Moderate Severe
effect effect
effect
8. Please tell me how much pain has had an effect on your
general activity in the past 24 hours?
Prompts: the things that you do each day (give appropriate
examples such as eating breakfast, selecting clothing for the
day, combing hair)
Please tick:
No effect Mild
Moderate Severe
effect effect
effect
9. In the past 24 hours, how much has pain had an effect on
your interactions with other people?
Prompts: chatting, saying hello, answering when others speak to
you, smiling at other people.
Please tick:
No effect
Mild
effect
Moderate
effect
Severe
effect
Now please think about your pain overall, whether it is in one
place or in more than one place.
Note: continue to use the chart showing No Pain/Mild/Moderate/
Severe if the resident is able to read the font.
THANK YOU

Module 3 - Clinical Care
Form 1: Modified Resident’s Verbal Pain Inventory (M-RVBPI) (continued)
Scoring the M-RVBPI
Items 2c, 4, 5, and 6 assess the intensity of pain as reported by
the resident. These items are best used to obtain a picture of the
level of the resident’s pain experience that can be summarised in
the Pain Intensity Summary.
Pain Intensity Summary
Item Pain Feature
1. Pain initially recalled in past 24 hours
Please tick: Yes No
2c. Pain on movement
No Pain Mild Moderate Severe
4. Pain worst in past 24 hours
No Pain Mild Moderate Severe
5. Pain least in past 24 hours
No Pain Mild Moderate Severe
6. Pain now
No Pain Mild Moderate Severe
Responses to items 7, 8 and 9 can be scored using the scale of
0 (no pain) to 3 (severe pain) and these scores can be summed
to give an overall score for pain interference. This score can be
documented in the Pain Interference Summary.
Pain Interference Summary
Item Area of interference Circle and transfer score to total.
7. Walking
0 No Pain 1 Mild 2 Moderate 3 Severe
Not Applicable
Recommended Uses of Scores
Obviously, responses for pain intensity and scores for pain
interference can be used for comparison purposes. This is
especially important when trialling an intervention to reduce
pain. However, responses and scores should also serve to alert
staff to the need to implement such an intervention.
Some key principles are that:
• Pain of moderate or severe intensity that cannot be
controlled by existing measures needs urgent review.
• Scores of 6 and over for pain interference, or four and over
when the resident cannot walk, also mean that urgent
review is required.
• Pain of any level of intensity that recurs, lasts for long
periods, and/or causes interference with walking, general
activity, or interactions must prompt the implementation
or review of pain management strategies.
8. General activity
0 No Pain 1 Mild 2 Moderate 3 Severe
Not Applicable
9. Interactions
0 No Pain 1 Mild 2 Moderate 3 Severe
Not Applicable
TOTAL PAIN SCORE /9

Module 3 - Clinical Care
Form 2: Abbey Pain Scale
For measurement of pain in people with dementia who
cannot verbalise.
Name of Resident:
Name and designation of person completing the scale:
Date:
Time:
Latest pain relief given was:
at
hours
How to use scale:
While observing the resident, score questions 1 to 6
1. Vocalisation
e.g. whimpering, groaning, crying
0 Absent 1 Mild 2 Moderate 3 Severe
2. Facial Expression
e.g. looking tense, frowning, grimacing, looking frightened
0 Absent 1 Mild 2 Moderate 3 Severe
3. Change in Body Language
e.g. fidgeting, rocking, guarding part of the body, withdrawn
0 Absent 1 Mild 2 Moderate 3 Severe
4. Behavioural Change
e.g. increased confusion, refusing to eat, alteration in
usual patterns
0 Absent 1 Mild 2 Moderate 3 Severe
5. Physiological Change
e.g. temperature, pulse or blood pressure outside normal limits,
perspiring, flushing or pallor
0 Absent 1 Mild 2 Moderate 3 Severe
6. Physical Changes
e.g. skin tears, pressure areas, arthritis, contractures,
previous injuries
0 Absent 1 Mild 2 Moderate 3 Severe
Now tick the circle that matches the Total Pain Score
0-2
No Pain
3-7
Mild
8-13
Moderate
Finally, tick the circle which matches the type of pain
Chronic
Acute
Acute on
Chronic
14+
Severe
TOTAL PAIN SCORE /18

Module 3 - Clinical Care
Form 3: Oral Health Assessment Tool
Name of Resident: Completed by: Date:
Resident: is independent needs reminding needs supervision needs full assistance
Will not open mouth Grinding or chewing Head faces down Refuses treatment
Is aggressive Bites Excessive head movement Cannot swallow well
Cannot rinse and spit
Will not take dentures out at night
Healthy Changes Unhealthy
Dental
Referral
Healthy Changes Unhealthy
Dental
Referral
Lips
Natural Teeth
Smooth, pink,
moist
Dry, chapped or
red at corners
Swelling or
lump, red/
white/ulcerated
bleeding/
ulcerated
at corners *
Yes
No
No decayed
or broken teeth
or roots
1- 3 decayed
or broken teeth/
roots, or teeth
very worn down
4 or more
decayed or
broken teeth/
roots or fewer
than 4 teeth, or
very worn down
teeth *
Yes
No
Tongue
Dentures
Normal moist,
roughness, pink
Patchy, fissured,
red, coated
Patch that is
red and/or
white/ulcerated,
swollen *
Yes
No
No broken areas
or teeth, worn
regularly, and
named
1 broken area or
tooth, or worn
1-2 hours per
day only or not
named
1 or more broken
areas or teeth,
denture missing /
not worn, need
adhesive, or not
named *
Yes
No
Gums and Oral Tissue
Oral Cleanliness
Moist, pink,
smooth,
no bleeding
Dry, shiny,
rough, red,
swollen, sore,
one ulcer/sore
spot, sore under
dentures
Swollen, bleeding,
ulcers, white/red
patches,
generalised
redness under
dentures *
Yes
No
Clean and no
food particles or
tartar in mouth
or on dentures
Food, tartar,
plaque 1-2 areas
of mouth, or on
small area of
dentures
Food particles,
tartar, plaque
most areas of
mouth, or on
most of dentures
*
Yes
No
Saliva
Dental Pain
Moist tissues
watery and
free flowing
Dry, sticky
tissues, little
saliva present,
resident thinks
they have a dry
mouth
Tissues parched
and red, very
little/no saliva
present, saliva
is thick, resident
thinks they have a
dry mouth *
Yes
No
No behavioural,
verbal or
physical signs
of dental pain
Verbal &/or
behavioural
signs of pain
such as pulling
at face, chewing
lips, not eating,
changed
behaviour.
Physical pain signs
(swelling of cheek
or gum, broken
teeth, ulcers), as
well as verbal &/or
behavioural signs
(pulling at face, not
eating, changed
behaviour) *
Yes
No
* Unhealthy signs usually indicate referral to a dentist is necessary
Assessor Comments

Module 3 - Clinical Care
Form 4: Oral Health Care Plan
Last Oral Health Assessment (OHA) Date:
(OHA) Review Due Date
Oral Health Care Considerations
Problems:
difficulty swallowing difficulty moving head difficulty opening mouth fear of being touched
Interventions:
bridging chaining hand over hand distraction (activity board/toy) rescue other
Daily Activities of Oral Hygiene
Morning
Natural Teeth
Yes No
clean teeth, gums,
tongue
Cleaned by:
Self Supervise Assist
After Lunch
rinse mouth with water
antibacterial product
(teeth & gums)
Night
clean teeth, gums,
tongue
Replace toothbrush (3 monthly) Date:
Denture
Full Partial
Upper Lower
Inserted/ removed by:
Self Staff
clean teeth, gums,
tongue
brush denture
rinse mouth with water
rinse denture
antibacterial product
(gums)
clean teeth, gums, tongue
brush denture with
mild soap
leave dentures out
overnight
Cleaned by:
Self Supervise Assist
soak denture in cold
water
Disinfect dentures (weekly) Specify day:
Oral Hygiene Aids
soft toothbrush modified toothbrush toothbrush grip denture brush spray bottle (labelled)
Oral Health Care Products
mild soap (denture)
antibacterial product
saliva substitute
lip moisturiser
high fluoride (5000 ppm) toothpaste
Additional Oral Care Instruction
antifungal gel
denture adhesive
interproximal brush
tongue scraper
normal saline mouth toilet
Check daily, document and report to RN if:
bad breath bleeding gums lip blisters/sores/cracks tongue for any coating/
change in colour
sore mouth or gums mouth ulcer swelling of face/mouth broken/lost denture
difficulty eating refusal of oral care denture not named excessive food left in mouth
broken teeth
Signed RN:
Date:

Module 3 - Clinical Care
Form 5: Confusion Assessment Method (CAM) - Shortened version
Name of resident:
Date of Birth:
Date: / / Time:
I. ACUTE ONSET AND FLUCTUATING COURSE
a) Is there evidence of an acute change in mental status from
the patient’s baseline?
b) Did the (abnormal) behaviour fluctuate during the day, that is
tend to come and go or increase and decrease in severity?
II. INATTENTION
Did the patient have difficulty focusing attention, for example, being easily
distractible or having difficulty keeping track of what was being said?
No
No
No
BOX 1
Yes
Yes
Yes
III. DISORGANISED THINKING
Was the patient’s thinking disorganised or incoherent, such as rambling or
irrelevant conversation, unclear or illogical flow of ideas, or unpredictable
switching from subject to subject?
IV. ALTERED LEVEL OF CONSCIOUSNESS
Overall, how would you rate the patient’s level of consciousness?
Alert (normal)
BOX 3
Vigilant (hyperalert)
Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse)
Coma (unarousable)
Do any checks appear in box 3?
No
No
BOX 2
Yes
Yes
If all items in Box 1 are ticked and at least
one item in Box 2 is ticked a diagnosis of
delirium is suggested.
Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI.
Clarifying confusion: The Confusion Assessment Method. A new method for detection
of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training
Manual and Coding Guide, Copyright 2003, Sharon K. Inouye, M.D., MPH