Use of Pain Tools for Pain Assessment Sherry Nolan MSN, RN 2009 FACES, FLACC, and N- PASS-- The 3 Approved Tools for CHLA.

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!”