Transcript Golden rule of Neonatal Pain management

Use of Pain Tools
for Pain
Assessment
Sherry Nolan MSN, RN
2009
FACES, FLACC, and NPASS-The 3 Approved Tools for
CHLA
Pain Assessment:
Background
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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
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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.)
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Hospital commitment to pain
management
Information about pain
management provided to
patient/families
Discharge plan for pain
management
Pain Assessment:
Definition
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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
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Starts with hx of pain
episode
Includes onset &
location
Radiation and
duration
Quality or description
Severity/intensity
/frequency
Exacerbating/precipitating/alleviating
factors
Impact on adl
Pain Assessment:
History
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Admission Data Base
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Words used for pain
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Must include info on current and past 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.)
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When pain is present, always
ascertain its:
Quality
Intensity
Location
Aggravating Factors
Alleviating Factors
Pain Assessment: Potential
Causes of Pain
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Preoperative/postoperative
Pain crisis
Acute, chronic, or episodic pain
Procedural pain
Other examples: Th??????ink of your
own examples…….
Pain Assessment:
Pain Rating Scales
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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
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Pain Assessment:
Pain Rating Scales
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Before using a pediatric pain tool….
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Assess developmental level
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Can child verbalize pain?
Can child use pain rating scale?
 Use the water test
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Use the appropriate scale
Pain Tools approved
for use at CHLA
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FLACC
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FACES
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N-PASS
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Verbal Self-report
limited to the visually
impaired
Pain Assessment:
Pain Rating Scales
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FLACC scale has 5 categories:
F
= Face
 L = Legs
 A = Activity
 C = Cry
 C = Consolability
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For preverbal or nonverbal children from
infancy to 7 years
Pain Assessment:
Pain Rating Scales
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FLACC
 Face
0
Scoring
= 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
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FLACC
 Legs
0
Scoring
= normal position or relaxed
 1 = uneasy, restless, tense
 2 = kicking, or legs drawn up
Pain Assessment:
Pain Rating Scales
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FLACC
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Activity Scoring
0 = lying quietly, normal position, moves
easily
 1 = squirming, shifting back and forth,
tense
 2 = arched, rigid, or jerking
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Pain Assessment:
Pain Rating Scales
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FLACC
 Cry
0
Scoring
= no cry (awake or asleep)
 1 = moans or whimpers;
occasional complaint
 2 = crying steadily, screams or
sobs, frequent complaints
Pain Assessment: Pain
Rating Scales
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FLACC
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Consolability Scoring
0
= content, relaxed
 1 = reassured by occasional
touching, hugging or being talked
to, distractible
 2 = difficult to console or comfort
FLACC Scale
0
Face
N o p a rtic u la r
E x p re ssio n ,
sm ile
L egs
N o rm a l
p o sitio n
O r re la x e d
L y in g q u ie tly
N o rm a l
p o sitio n
M o v e s e a sily
N o c ry
(A w a k e o r
a sle e p )
A c tiv ity
C ry
C o n so la b ility
C o n te n t,
re la x e d
1
2
O c c a sio n al
g rim ac e o r
fro w n
W ith d ra w n ,
d isin te re ste d
U n e a sy ,
re stle ss, te n se
F re q u e n t to
c o n sta n t
fro w n ,
c le n c h e d ja w ,
q u iv e rin g c h in
K ic k in g o r
L e g s d ra w n u p
S q u irm in g ,
sh iftin g
b a c k /fo rth ,
T e n se
M o a n s,
w h im p e rs,
O c c a sio n al
c o m p lain t
A rc h e d , rig id ,
o r je rk in g
R e a ssu re d b y
o c c a sio n a l
to u c h in g ,
h u g g in g , o r
ta lk in g to
d istra c tib le
C ry in g
ste a d ily ,
sc re a m s o r
so b s, fre q u e n t
c o m p lain ts
D iffic u lt to
c o n so le o r
c o m fo rt
Pain Assessment:
Pain Rating Scales
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Wong/Baker FACES Scale
For children aged 3 to young adults
 Cartoon faces from 0 (no hurt) to 10
(hurts worst)
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Use script to administer first few times
 Now on white boards in all rooms
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Pain Assessment:
Pain Rating Scales
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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
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Interventions are based on scores
Intervention for pain score of >3
Reassess within 1 hour of
intervention
Pain Assessment:
Policies and Procedures
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Refer to Policy & Procedure:
“Pain Management & Assessment
of Pain in Neonates, Infants,
Children, Adolescents and Young
Adults”COP-8”
Additional Web
Links
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Comparison of Pediatric Pain tool
Pediatric Pain Management U
Mich
N-PASS
Golden Rule of Neonatal
Pain Management
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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
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Surgical
procedures
Invasive/indwelling
tubes
Heelsticks
Arterial punctures
Suctioning
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Peritonitis
Fractures
Renal stones
Noxious
environment
Damaged skin
integrity
Neonatal Pain Tool
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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
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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
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Premies are given up to 3
additional points based on their
gestation
Pain and sedation scores are
scored separately
Goals of pain
treatment
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The score should be < 3 usually
Show a decrease in the pain
score
Sedation Score
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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
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When sedation of the infant is a
goal
When sedation--or oversedation-- is a side effect of
analgesia or sedative
administration
Levels of Sedation
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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
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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
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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.
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Guides the
continued care
plan
Adjust p.m.
regime to clinical
reassessment
findings &
understanding of
pharmacology,
non-pharm rx, &
the individual
patient.
Customization,
collaboration
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Use a multimodal
approach with
regard to
pharmacologic
agents-peripheral
& central relief
Nonpharmacologic:
heat/cold;relaxation
techniques;distraction
Policies &
Procedures
COP 8, Assessment &
Management of Pain in
Infants, Children & Young
Adults
Pain management is
a patient right
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Nurses must
make a conscious
commitment to
support this right
“It’ s good thing!”