Use of Pain Tools for Pain Assessment Sherry Nolan MSN, RN 2009

1. Use of Pain Tools for Pain AssessmentSherry Nolan MSN, RN2009 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 • ActivityScoring • 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. Surgical procedures Invasive/indwelling tubes Heelsticks Arterial punctures Suctioning Peritonitis Fractures Renal stones Noxious environment Damaged skin integrity Actual or potential causes of pain

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. 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. Continuous reassessment

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!”