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

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Presentation on theme: "Use of Pain Tools for Pain Assessment Sherry Nolan MSN, RN 2009 FACES, FLACC, and N- PASS-- The 3 Approved Tools for CHLA."— Presentation transcript:


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

3 Pain Assessment: Background n American Pain Society - Quality Assurance Standards for Relief of Acute Pain and Cancer Pain. n Agency for Health Care Policy & Research guidelines,1990 n TJC – The Joint Commission standards n All these agencies mandate the need for objective assessment and treatment of pain in all patients

4 JCAHO Standards Pain Assessment n The following must be included: n Intensity, Location, Quality n Alleviating, Aggravating Factors n Pain history, treatment regimen & effectiveness n Impact of pain on daily life

5 TJC Standards (Cont.) n Hospital commitment to pain management n Information about pain management provided to patient/families n Discharge plan for pain management

6 Pain Assessment: Definition n McCafferys definition of pain: whatever the experiencing person says it is, existing whenever he or she says it does. n Patient self-report measures are the gold standard n Healthcare providers and parents underrate childrens pain

7 Pain History n Starts with hx of pain episode n Includes onset & location n Radiation and duration n Quality or description n Severity/intensity /frequency n Exacerbating/precipi- tating/alleviating factors n Impact on adl

8 Pain Assessment: History n Admission Data Base u Must include info on current and past pain n Words used for pain u Should be clarified and documented for clarity n Note social, cultural & spiritual influences that may affect the patients pain experience. n If pain is present on admission or at any time, implement the standardized MPC for acute pain.Dont forget the teaching section! n Separate MPC for SCD crisis/& teaching section

9 Pain Assessment : History (Cont.) n When pain is present, always ascertain its: n Quality n Intensity n Location n Aggravating Factors n Alleviating Factors

10 Pain Assessment: Potential Causes of Pain n Preoperative/postoperative n Pain crisis n Acute, chronic, or episodic pain n Procedural pain n Other examples: Th??????ink of your own examples…….

11 Pain Assessment: Pain Rating Scales n Goals: u to identify intensity of pain u to establish a baseline assessment u to evaluate pain status u to evaluate effects of intervention u meeting professional,ethical, and regulatory requirements

12 Pain Assessment: Pain Rating Scales n Before using a pediatric pain tool…. u Assess developmental level u Can child verbalize pain? u Can child use pain rating scale? u Use the water test u Use the appropriate scale

13 Pain Tools approved for use at CHLA n FLACC n FACES n N-PASS n Verbal Self-report limited to the visually impaired

14 Pain Assessment: Pain Rating Scales n FLACC scale has 5 categories: u F = Face u L = Legs u A = Activity u C = Cry u C = Consolability n For preverbal or nonverbal children from infancy to 7 years

15 Pain Assessment: Pain Rating Scales n FLACC u Face Scoring F 0 = no particular expression or smile F 1 = occasional grimace or frown, withdrawn, disinterested F 2 = frequent to constant quivering of chin, clenched jaw

16 Pain Assessment: Pain Rating Scales n FLACC u Legs Scoring F 0 = normal position or relaxed F 1 = uneasy, restless, tense F 2 = kicking, or legs drawn up

17 Pain Assessment: Pain Rating Scales n FLACC u Activity Scoring F 0 = lying quietly, normal position, moves easily F 1 = squirming, shifting back and forth, tense F 2 = arched, rigid, or jerking

18 Pain Assessment: Pain Rating Scales n FLACC u Cry Scoring F 0 = no cry (awake or asleep) F 1 = moans or whimpers; occasional complaint F 2 = crying steadily, screams or sobs, frequent complaints

19 Pain Assessment: Pain Rating Scales n FLACC u Consolability Scoring F 0 = content, relaxed F 1 = reassured by occasional touching, hugging or being talked to, distractible F 2 = difficult to console or comfort

20 FLACC Scale

21 Pain Assessment: Pain Rating Scales n Wong/Baker FACES Scale u For children aged 3 to young adults u Cartoon faces from 0 (no hurt) to 10 (hurts worst) u Use script to administer first few times u Now on white boards in all rooms

22 Pain Assessment: Pain Rating Scales n Verbal Self-Report u For patients who are visually impaired only u Ask to rate pain on a scale of zero indicating no pain and ten indicating worst possible pain

23 Pain Assessment: Pain Rating Scores and Treatment n Interventions are based on scores n Intervention for pain score of >3 n Reassess within 1 hour of intervention

24 Pain Assessment: Policies and Procedures n Refer to Policy & Procedure: n Pain Management & Assessment of Pain in Neonates, Infants, Children, Adolescents and Young AdultsCOP-8

25 Additional Web Links n Comparison of Pediatric Pain tool Comparison of Pediatric Pain tool n Pediatric Pain Management U Mich Pediatric Pain Management U Mich


27 Golden Rule of Neonatal Pain Management n Pain should be presumed in all neonates in all situations that are usually identified as painful in adults or children n Pain treatment should be instituted in all cases where pain is presumed

28 Actual or potential causes of pain n Surgical procedures n Invasive/indwelling tubes n Heelsticks n Arterial punctures n Suctioning n Peritonitis n Fractures n Renal stones n Noxious environment n Damaged skin integrity

29 Neonatal Pain Tool n No Neonatal pain tool is perfect n Multidimensional pain tools that look at more than one sign of pain [cry, behavior, vital sign changes, etc] are preferred over unidimensional tools n 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]



32 Pain Interventions n Should be initiated for scores of > 3 n Some older infants may have an increased baseline score, interventions should then be instituted for consistent elevations. n Those weaning from opioids may have increased scores

33 N-PASS Idiosyncrasies n Premies are given up to 3 additional points based on their gestation n Pain and sedation scores are scored separately

34 Goals of pain treatment n The score should be < 3 usually n Show a decrease in the pain score

35 Sedation Score n Scored to assess response to stimuli n Though sedation need not be scored with every VS, Sedation should be scored: u With hands-on VS u When patients are on analgesics or sedatives u When stimulation of the baby is necessary, e.g heelsticks, suctioning, position changes u Baby should not be stimulated unnecessarily to assess the sedation score

36 N-PASS Sedation Score- Utility n When sedation of the infant is a goal n When sedation--or over- sedation-- is a side effect of analgesia or sedative administration

37 Levels of Sedation n Noted on N-PASS as negative scores n Desired levels vary based on treatment goals n Deep sedation [avoided unless patient is on mechanical ventilation] = -10 to - 5 n Light sedation = -5 to –2

38 Negative sedation score interpretation n Sedation has been achieved or is a by product of medication administration n May also indicate neurological depression, sepsis, or other pathology n May indicate a pain response in a premie who is shut down in the face of prolonged or unrelieved pain or stress.

39 Continuous reassessment n Reassessment is key to successful pain management n Should occur on a routine basis after an initial report of pain & after each intervention to document the effectiveness of the intervention. n Guides the continued care plan n Adjust p.m. regime to clinical reassessment findings & understanding of pharmacology, non-pharm rx, & the individual patient.

40 Customization, collaboration n Use a multimodal approach with regard to pharmacologic agents-peripheral & central relief n Non- pharmacologic: heat/cold;relaxa- tion techniques;dis- traction

41 Policies & Procedures COP 8, Assessment & Management of Pain in Infants, Children & Young Adults

42 Pain management is a patient right n Nurses must make a conscious commitment to support this right n It s good thing!

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