Policy Manual sample

MDT Home Health Care Agency, Inc. * Impact of pain on the patient’s quality of life, i.e., impact on activities of daily living, sleep, appetite, relationships with others, emotions, concentration * Pain management history, including medication history, presence of barriers to reporting pain and using analgesics and/or complementary therapies, manner of expressing pain * Patient’s and family’s pain management goals * The Registered Nurse/Therapist: * Formulates, implements and updates the pain management plan of care based on assessment findings in collaboration with the patient/family and communicates this plan to other members of the healthcare team. * Assesses the patient’s pain and evaluate his/her response to pain management interventions using a standard pain management tool based on the patient’s self- report during each visit. * Assesses the patient for adequate pain control, bowel elimination, change in level of consciousness/cognitive function, general behavior, social interactions and nutritional status. * Monitors and assesses the patient for the side effects of medications on an ongoing basis and implements measures to combat/manage the side effects based on clinical practice guidelines. * Instructs the patient/family/caregiver in noninvasive/complementary interventions to assist in the alleviation of pain, i.e., massage, meditation, stress reduction techniques. * Instructs the patient/family/caregiver in a culturally competent manner regarding appropriate expectations for pain management. * Provides patients and families with educational materials and community resources to assist with pain management. * Documents pain assessment, interventions and evaluation activities in accordance with the Agency Policy. * Communicates the effectiveness of the pain management plan to the Clinical Supervisor and physician at least weekly and more often if necessary. * Request physician orders for a social service referral, if appropriate, based upon the patient’s needs, response to care, treatment and/or services and clinical status. Home Health Agency Nursing Manual J-49