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

2. 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

3. 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

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

5. 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

6. 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

7. 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

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

9. 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…….

10. 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

11. 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

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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. FLACC Scale

20. 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

21. 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”

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

23. Pain Assessment: Policies and Procedures
Refer to Policy & Procedure:
“Pain Management & Assessment of Pain in Neonates, Infants, Children, Adolescents and Young Adults”COP-8”

24. Additional Web Links Comparison of Pediatric Pain tool
Pediatric Pain Management U Mich

25. N-PASS

26. 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

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

28. 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]

29. For Pain Assessment
"0" = no pain behaviors

30. Sedation Score
"0" = no signs of sedation

31. 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

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

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

34. 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

35. 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

36. 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

37. 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.

38. 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.

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

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

41. Pain management is a patient right
Nurses must make a conscious commitment to support this right
“It’ s good thing!”