pain assessment najmeh ajoodanian, ms, nicu 2014

PAIN AssessmentPAIN Assessment

Najmeh Ajoodanian, MS, NICU

2014

Pain Perception

• 28 week of gestation

• pain threshold that is 30% to 50% lower than that of adults

• lower pain tolerance than older children

• Premature infants are even more hypersensitive to nociceptive stimuli than full-term infants

• As the fifth vital sign,

• pain needs to be monitored routinely

in the clinical practice

• infants cannot speak and advocate

Pain . . .

Pain . . .

• Pain assessment and measurement are the cornerstones of pain management

• The purpose of this review pain measures in both preterm and full term newborns by introducing a conceptual framework

The International Association for the Study of Pain

(IASP)

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described

in terms of such damage.”

“Pain is subjective”

defines pain

FRAMEWORK FOR MEASUREMENT OF NEONATAL PAIN

Neonatal Pain Responses

• Behavioral

• Physiologic

• Autonomic

• Biochemical

Behavioral Pain Responses

• Facial expression cleaning the heel or changing diapers

• Facial expression include:

• facial grimacing, brows bulged and furrowed

• eye squeezed, nasolabial furrowing,

• lips opened and pursed, cupped tongue, quivering chin

• agitation.

Crying is a common response to pain in infants

preterm and acutely ill infants may not audibly cry during heel sticks and other painful procedures silent cry

Observations of gross motor responses including:

• body movements of arms, legs and trunks,

• Whole body, finger splay and fisting,

• attempts to withdraw from a painful stimulus

Observation sleep wake alterations

Physiologic Responses

• increases in heart rate, respiratory rate, blood pressure

• increases intracranial pressure, and palmar sweating

• decreases in transcutaneous oxygen saturation, vagal tone, and peripheral blood flow

Autonomic Responses

• changes in skin color, nausea, vomiting, gagging

• hiccoughing, diaphoresis, palmar sweating

• dilated pupils

Biochemical Responses

• increased secretion of catecholamines (ie, norepinephrine and epinephrine), glucagon, and corticosteroids or cortisol

• decreased prolactin, insulin, and immune responses

Infant Contextual Parameters inPain Assessment

• Age

• Previous pain experiences

• Gender

• Health status

• especially in preterm infants

Health providers’ knowledge, ability, and

attitudes toward neonatal pain are

significant factors in observation, and using

appropriate pain tools to recognize a

neonate’s pain.

PAIN ASSESSMENT TOOLS

1. Unidimensional Tools

2. Multidimensional Tools

Unidimensional Infant Pain Measures

• Designed for measurement of acute/procedural pain

• MAX: Maximally Discriminative Facial Coding System

• NFCS: Neonatal Facial Coding System

• IBCS: Infant Body Coding System;

• DAN: Douleur Aiguë du

• BIIP: Behavioral Indicator of Infant Pain

Unidimensional Infant Pain Measures

• Designed for measurement of postoperative pain

• CSS: Clinical Scoring System

• LIDS: Livepool Infant Distress Scale

• FLACC: Face, legs, activity, cry, consolability

• UWCH: University of Wisconsin Children’s Hospital Pain Scale

• CHIPPS: Children’s and Infant’s Postoperative

• Pain Scale

Unidimensional Infant Pain Measures

Designed for measurement of prolonged pain

•BPS: Behavioral Pain Score

•EDIN: Echelle Douleur Inconfort Nouveau-Ne Neonatal Pain and Discomfort Scale

•COMFORTneo: modified from the COMFORT

Multidimensional Infant Pain Measures

Designed for measurement of acute/procedural pain

•NIPS: Neonatal Infant Pain Scale;

•NPAT: Neonatal Pain Assessment Tool

•PIPP: Premature Infant Pain Profile

•DSVNI: Distress Scales for Ventilated Newborn

•Infants

Multidimensional Infant Pain Measures

Designed for measurement of acute/procedural pain

•SUN: Scale for Use in Newborns

•PAIN: Pain Assessment in Neonates

•BPSN: Bernese Pain Scale for Neonates

•FANS: Faceless Acute Neonatal Pain Scale

Multidimensional Infant Pain Measures

Designed for measurement of postoperative pain

•COMFORT Scale (not primarily developed for neonates

•PAT: Pain Assessment Tool

•CRIES

•MIPS: L Modified Infant Pain

•MAPS: Multidimensional Assessment Pain Scale;

Multidimensional Infant Pain Measures

Designed for measurement of prolonged/ongoing pain

•N-PASS: Neonatal Pain, Agitation, and Sedation Scale

Premature Infant Pain Profile

CRIES scale

• C-crying

• R-requires O2

• I-increased VS

• E-expression

• S-sleepless

Simple and easy to use-uses a scale of 1-10, similar to APGAR scoring

score of 4 or greater requires intervention

objective and behavioral categories

FLACC Scale

• F-face (expression)

• L-legs (tone)

• A-activity

• C-cry

• C-consolability

score is tallied, similar to APGAR (0,1, or 2 for each category)

greater than 4 is indicative of pain

behaviorally based

Measure Age Level Indicator Pain Stimulus

CRIES

Preterm & Full- term Up to 60 Weeks gestation age

Crying, requires O2 for saturation, increased vital signs (HR and BP), expression, sleepless

Postoperative Pain

BPSN

Preterm & Full- term neonates Time to calm, skin color, eyebrow bulge with eye squeeze, posture, breathing pattern, heart rate, oxygen saturation

Procedural pain in neonates with or without ventilation

NIPS Preterm & Full- term neonates Facial expression, cry, breathing pattern, arms, legs, state of arousal

Procedural pain

PAT

Full- term neonates Posture, tone, sleep pattern, expression, color, cry, respiration, heart rate, oxygen saturation, blood pressure, nurses perception of infant pain

postoperative pain

PIPP

Preterm & Full- term neonates Gestational age, behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, nasolabial furrow

Procedural and postoperative pain

SUN

Preterm & Full- term infants Central nervous system state, breathing, movement, tone, face, heart rate, blood pressure

Procedural pain

New Techniques for Pain Measurement

• Heart Rate Variability

• Skin Conductance

• Brain-Oriented Approach

Thank you for your attention

32

If you have any question contact to:

ajoodaniyan@yahoo.com

References

Cong X. Cusson RM. Pain Assessment and Measurement. Foundations in Newborn Care. 2013;379-395

Kenner C, Lott JW. Comprehensive Neonatal care an interdisciplinary approach chapter 17: Pain in the Newborn and Infant . 2010

Verklan MT, Walden M. Care curriculum for Neonatal intensive care unit 2010