Use of Pain Tools for Pain Assessment Sherry 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 Scale

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 Peritonitis Fractures Renal stones Noxious environment Damaged skin integrity Surgical procedures Invasive/indwelling tubes Heelsticks Arterial punctures Suctioning

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]

For Pain Assessment "0" = no pain behaviors

Sedation Score "0" = no signs of sedation

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!”