Consistent Pain Assessment in the Neonatal Intensive Care Unit

By Suzanne D. Tietjen, RNC, BSN, CCRN, NNP
Abstract presented at The Physical and Developmental Environment of the High-Risk Neonate Conference, St. Petersburg Beach, FL, 2001.

Infants in our Neonatal Intensive Care Unit (NICU) at the Children's Hospital of Illinois undergo many painful procedures. Pain assessment for our small patients was subjective and inconsistent. Treatment varied by caregiver. We wanted be part of the "Ouchless" Children's Hospital Movement, preventing as much pain as possible; effectively relieving pain; and helping infants and families cope when pain was unavoidable.

First, we presented a Neonatal Grand Rounds that focused on premature and newborn infants as a uniquely vulnerable population. We presented current best evidence to correct many misconceptions about pain in infants, as well as to explain the ways that unrelieved pain can harm newborns.

A multidisciplinary group of volunteers formed a task force using CQI (Continuous Quality Improvement) methods to define the problem and explore possible solutions. We asked for input from the NICU as a whole, benchmarked with other units, searched the literature for infant pain assessment tools and tried each pain scale on various infants in our NICU. We chose The Neonatal Pain Assessment Scale which is based on The Attia Scale and was developed by Susan Givens Bell at All Children's Hospital in St. Petersburg, Florida. This scale seemed best suited to our patients, who are nonverbal, immature, often intubated, and critically ill. This scale incorporates both physiologic and behavioral parameters, and takes into account attempts to console the infants during evaluation. One of our staff nurses reformatted the scale so it could be printed on our flow sheet and be user-friendly to the nursing staff.

We then adapted our 24-Hour Flowsheet, daily progress note, and admission data base to include pain assessment expressed as a score from 0 to 10 which was charted directly under the vital signs. The American Pain Society (APS) suggests that documenting pain assessment with the vital signs raises awareness of the problem of pain.

While these changes were being approved, our task force began a season-long education project. Members of the task force posted "short subject" pain posters in the bathroom stalls. Each colorful poster listed the harmful effects of unrelieved pain on an organ system. At the end of the season, there was a contest/post-test with prizes for participation and a grand prize drawing from the correct entries. (Our unit likes to have a little fun while we learn.)

We are receiving positive feedback from our staff in the NICU, as well as the hospital-wide committees on pain. Operational definitions for the pain scale are available in each room, and a pain vs. agitation algorithm and pain scale guidelines have been laminated for nurses to place on their key rings of clinical information.

Our focus now is shifting to education for our families. We are making signs for the waiting areas and scrub sinks that will tell them that we think pain management is a very important part of their infants' care. We are encouraging their involvement and are adapting our family handbook to include how we evaluate their infants' comfort and helping them to read their infants' behavior so we as a team can meet the babies' needs.

This team approach to pain management in the NICU takes advantage of many viewpoints and areas of expertise. Nurses are pivotal, as they will be the most frequent assessors of pain scores, effectiveness of treatment, and the need to revise the treatment plan. Using this pain scale improves communication and consistency between caregivers. We expect our management of pain to develop and change as new evidence emerges. Consistent assessment is the first step to preventing and relieving pain in sick and preterm newborns. By providing these smallest of patients with the best pain management possible, we can help them to recover, grow, and attain their highest quality of life.

Neonatal Grand Rounds
Misconceptions About Infant Pain

Old School of Thought:

1. Newborns do not feel pain because their nervous systems are too immature.
2. Even if newborns do feel pain, they cannot remember it.
3. Even if they feel or remember pain, it doesn't cause them harm.
4. Even if newborns feel or remember pain, and, even if it is harmful to them; we cannot safely give them local or systemic analgesia or anesthesia.

Evidence Suggests:

1. Peripheral receptors, nerve pathways, and the cerebral cortex function to process pain by mid-gestation (Anand, 1993).
2. Research and anecdotal experience show that newborns react with distress behaviors to actions that have preceded painful interventions in the past.
3. Untreated pain has physical effects and can increase morbidity and mortality.
4. Analgesia, sedation, and anesthesia can be safely provided to newborns in most circumstances.

Newborns are as sensitive to pain as adults, AND preterm infants are more sensitive to pain. Neurotransmitters in the dorsal horn of the spinal cord are associated with nociception and increased somatosensory excitability in the preterm spinal cord. On the other hand, neurotransmitters in descending inhibitory nerve fibers are only present at term. Thus, there is diminished inhibition of pain in premature infants.

Suzanne D. Tietjen is a neonatal nurse practitioner at the Children's Hospital of Illinois. She became very interested in the effects of pain on babies when she began to do painful but life-saving procedures as an advanced practice registered nurse. She leads the Pain Task Force in her Neonatal Intensive Care Unit, working as part of a team to prevent/manage pain in this vulnerable population. She has written articles for publication and has been listed in Who's Who in America. Her most important work is helping the healthcare team act as advocates for infants in pain. They cannot speak for themselves, so their caregivers must learn how to tell if they hurt and do everything in their power to relieve their suffering.