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Use of Pain Tools for Pain
AssessmentSherry Nolan MSN, RN
2009
FACES, FLACC, and N-PASS--
The 3 Approved Tools for CHLA
Pain Assessment: Background American Pain Society - “Quality Assurance
Standards for Relief of Acute Pain and Cancer Pain.”
Agency for Health Care Policy & Research guidelines,1990
TJC – The Joint Commission standards All these agencies mandate the need for
objective assessment and treatment of pain in all patients
JCAHO Standards
Pain Assessment The following must be included:
Intensity, Location, Quality Alleviating, Aggravating Factors Pain history, treatment regimen &
effectiveness Impact of pain on daily life
TJC Standards (Cont.) Hospital commitment to pain
management
Information about pain management provided to patient/families
Discharge plan for pain management
Pain Assessment: Definition
McCaffery’s definition of pain: “whatever the experiencing person says it is, existing whenever he or she says it does.”
Patient self-report measures are the gold standard
Healthcare providers and parents underrate children’s pain
Pain History Starts with hx of pain
episode Includes onset &
location Radiation and
duration Quality or description Severity/intensity
/frequency Exacerbating/precipi-
tating/alleviating factors
Impact on adl
Pain Assessment: History
Admission Data Base Must include info on current and past pain
Words used for pain Should be clarified and documented for clarity
Note social, cultural & spiritual influences that may affect the patient’s pain experience.
If pain is present on admission or at any time, implement the standardized MPC for acute pain.Don’t forget the teaching section!
Separate MPC for SCD crisis/& teaching section
Pain Assessment : History (Cont.)
When pain is present, always ascertain its:
Quality Intensity Location Aggravating Factors Alleviating Factors
Pain Assessment: Potential Causes of
Pain
Preoperative/postoperative Pain crisis Acute, chronic, or episodic pain Procedural pain Other examples: Th??????ink of your
own examples…….
Pain Assessment: Pain Rating Scales
Goals: to identify intensity of pain to establish a baseline assessment to evaluate pain status to evaluate effects of intervention meeting professional,ethical, and
regulatory requirements
Pain Assessment: Pain Rating Scales
Before using a pediatric pain tool…. Assess developmental level
Can child verbalize pain?
Can child use pain rating scale? Use the water test
Use the appropriate scale
Pain Tools approved for use
at CHLA FLACC
FACES
N-PASS
Verbal Self-report limited to the visually impaired
Pain Assessment: Pain Rating Scales
FLACC scale has 5 categories: F = Face L = Legs A = Activity C = Cry C = Consolability
For preverbal or nonverbal children from infancy to 7 years
Pain Assessment: Pain Rating Scales
FLACC Face Scoring
0 = no particular expression or smile
1 = occasional grimace or frown, withdrawn, disinterested
2 = frequent to constant quivering of chin, clenched jaw
Pain Assessment: Pain Rating Scales
FLACC Legs Scoring
0 = normal position or relaxed 1 = uneasy, restless, tense 2 = kicking, or legs drawn up
Pain Assessment: Pain Rating Scales
FLACC Activity Scoring
0 = lying quietly, normal position, moves easily
1 = squirming, shifting back and forth, tense
2 = arched, rigid, or jerking
Pain Assessment: Pain Rating Scales
FLACC Cry Scoring
0 = no cry (awake or asleep) 1 = moans or whimpers;
occasional complaint 2 = crying steadily, screams or
sobs, frequent complaints
Pain Assessment: Pain Rating Scales
FLACC Consolability Scoring
0 = content, relaxed 1 = reassured by occasional
touching, hugging or being talked to, distractible
2 = difficult to console or comfort
FLACC Scale0 1 2
Face No particularExpression,smile
Occasionalgrimace orfrownWithdrawn ,disinterested
Frequent toconstantfrown,clenched jaw,quivering chin
Legs NormalpositionOr relaxed
Uneasy,restless, tense
Kicking orLegs drawn up
Activity Lying quietlyNormalpositionMoves easily
Squirming,shiftingback/forth,Tense
Arched, rigid,or jerking
Cry No cry(Awake orasleep)
Moans,whimpers,Occasionalcomplaint
Cryingsteadily,screams orsobs, frequentcomplaints
Consolability Content, relaxed
Reassured byoccasionaltouching,hugging, ortalking todistractible
Difficult toconsole orcomfort
Pain Assessment: Pain Rating Scales
Wong/Baker FACES Scale For children aged 3 to young adults Cartoon faces from 0 (no hurt) to 10 (hurts worst) Use script to administer first few times Now on white boards in all rooms
Pain Assessment: Pain Rating Scales
Verbal Self-Report For patients who are visually
impaired only Ask to rate pain on a scale of zero
indicating “no pain” and ten indicating “worst possible pain”
Pain Assessment: Pain Rating Scores and
Treatment
Interventions are based on scores Intervention for pain score of >3 Reassess within 1 hour of
intervention
Pain Assessment: Policies and Procedures
Refer to Policy & Procedure: “Pain Management & Assessment
of Pain in Neonates, Infants, Children, Adolescents and Young Adults”COP-8”
Additional Web Links Comparison of Pediatric Pain tool
Pediatric Pain Management U Mich
N-PASS
Golden Rule of Neonatal Pain Management
Pain should be presumed in all neonates in all situations that are usually identified as painful in adults or children
Pain treatment should be instituted in all cases where pain is presumed
Actual or potential causes of pain
Surgical procedures
Invasive/indwelling tubes
Heelsticks Arterial punctures Suctioning
Peritonitis Fractures Renal stones Noxious
environment Damaged skin
integrity
Neonatal Pain Tool No Neonatal pain tool is perfect Multidimensional pain tools that look at
more than one sign of pain [cry, behavior, vital sign changes, etc] are preferred over unidimensional tools
The N-PASS [Neonatal Pain, Agitation, and Sedation Scale] will be used for all neonates < 44 weeks post-conceptual age.. [Puchalski and Hummel, Loyola University Medical Hospital]
Pain Interventions Should be initiated for scores of
> 3 Some older infants may have an
increased baseline score, interventions should then be instituted for consistent elevations.
Those weaning from opioids may have increased scores
N-PASS Idiosyncrasies
Premies are given up to 3 additional points based on their gestation
Pain and sedation scores are scored separately
Goals of pain treatment
The score should be < 3 usually
Show a decrease in the pain score
Sedation Score Scored to assess response to stimuli Though sedation need not be scored with
every VS, Sedation should be scored: With hands-on VS When patients are on analgesics or sedatives When stimulation of the baby is necessary, e.g
heelsticks, suctioning, position changes Baby should not be stimulated unnecessarily
to assess the sedation score
N-PASS Sedation Score- Utility
When sedation of the infant is a goal
When sedation--or over-sedation-- is a side effect of analgesia or sedative administration
Levels of Sedation Noted on N-PASS as negative
scores Desired levels vary based on
treatment goals Deep sedation [avoided unless
patient is on mechanical ventilation] = -10 to - 5
Light sedation = -5 to –2
Negative sedation score interpretation
Sedation has been achieved or is a by product of medication administration
May also indicate neurological depression, sepsis, or other pathology
May indicate a pain response in a premie who is “shut down” in the face of prolonged or unrelieved pain or stress.
Continuous reassessment Reassessment is
key to successful pain management
Should occur on a routine basis after an initial report of pain & after each intervention to document the effectiveness of the intervention.
Guides the continued care plan
Adjust p.m. regime to clinical reassessment findings & understanding of pharmacology, non-pharm rx, & the individual patient.
Customization, collaboration Use a multimodal
approach with regard to pharmacologic agents-peripheral & central relief
Non-pharmacologic: heat/cold;relaxa-tion techniques;dis-traction
Policies & Procedures
COP 8, Assessment & Management of Pain in Infants, Children & Young Adults
Pain management is a patient right
Nurses must make a conscious commitment to support this right
“It’ s good thing!”