Neonatal Pain Assessment Scale
© 1993-1994 Susan Givens Bell
| SCORE | |||
| BEHAVIORAL CUES | 1 | 0.5 | 0 |
| 1. Sleep during preceding hour | none | short naps 5-10 minutes | longer naps 10+ minutes |
| 2. Facial expression of pain | marked constant | less marked intermittent | calm, relaxed |
| 3. Spontaneous motor activity | thrashing, incessant agitation or no activity | moderate agitation or decreased activity | normal |
| 4. Overall tone | strong hypertonicity or hypotonicity, flaccid | moderate hypertonicity or moderate hypotonicity | normal |
| 5. Consolability | none after 2 minutes | quiet after 1 minute of effort | quiet within 1 minute |
| 6. Cry | vigorous cry | whimper | no cry |
| PHYSIOLOGIC CUES | 1 | 0.5 | 0 |
| 7. Heart Rate | >20% increase | 10-20% increase | within baseline |
| 8. Blood Pressure (systolic) | >10mm Hg increase | 10mm Hg increase | within baseline |
| 9. Respiratory Frequency & Pattern | apnea or tachypnea | periodic breathing | within baseline |
| 10. SaO2 | >10% increase in FIO2 | < or =10% increase in FIO2 | no increase in FIO2 |
An infant with a score of 0-2.5 will arbitrarily be considered to have adequate pain control. | |||
Consistent Pain Assessment in the Neonatal Intensive Care Unit
Guideline for use of the Neonatal Pain Assessment Scale:
Operational definitions for the criteria evaluated in the scale
© 1993-1994 Susan Givens Bell
| SLEEP | |
| 1 - none | Awake continuously, fussy, hyperalert, restless, and thrashing. |
| 0.5 - short naps | Sleeps quietly and peacefully only 5-10 minutes out of an hour. |
| 0 - longer naps | Sleeps quietly and peacefully 10 or more minutes out of an hour. |
| FACIAL EXPRESSION OF PAIN | |
| 1- marked, constant | A continuous grimace, with tight facial muscles, furrowed brown, eyes squeezed tightly shut and a deepened nasa-labial furrow. |
| 0.5 - less marked, intermittent | An occasional frown or grimace. |
| 0 - calm, relaxed | Restful, neutral facial expression. |
| SPONTANEOUS MOTOR ACTIVITY | |
| 1- trashing, agitation or no activity | Incessant gross motor movement of arms, legs and/or torso - does not readily respond to comfort measures. No spontaneous movements of extremities or body. |
| 0.5 - moderate hypertonicity | Extension of arms, legs, and/or torso, some flexion may be noted. |
| 0 - normal | Usual tone for this infant. |
| CONSOLABILITY | |
| 1- Vigorous cry | Loud scream, shrill, rising, continuous. If intubated-silent cry with obvious mouth and facial movements. |
| 0.5 - whimper | Mild, intermittent moaning, may only be audible with stethoscope |
| 0 - no cry | Quiet, not crying |
| HEART RATE | |
| 1 - >20% increase | >20% increase over baseline (pre-painful event) assessment |
| 0.5 - 10-20% increase | 10-20% increase over baseline (pre-painful event) assessment |
| 0 - within baseline | Heart rate is consistent with normal range for this infant. |
| BLOOD PRESSURE (SYSTOLIC) | |
| 1 - >10 mm Hg increase | >10 mm Hg increase in systolic blood pressure over baseline assessment. |
| 0.5 - 10 mm Hg increase | 1- mm Hg increase in systolic blood pressure over baseline assessment. |
| 0 - within baseline | Systolic blood pressure is consistent with normal range for this infant. |
| RESPIRATORY FREQUENCY & PATTERN | |
| 1 - apnea or tachypnea | Cessation of respirations >20 seconds, may also be scored if infant makes no spontaneous respiratory effort while ventilated. Respiratory rate >60 (if not ventilated at rate >60) with our without retractions. | 0.5 - periodic breathing | Cessation of respirations for 10-15 second periods, may be followed by periods of tachypnea and/or labored respirations. |
| 0 - within baseline | Respiratory rate and pattern normal for this infant. |
| SaO2 | |
| 1 - >10% increase in FI02 | requires >10% increase in Fl02 to maintain oxygen saturation within prescribed range for this infant. The FIO2 on which the infant returns from the OR, will be the starting baseline Fl02 for the post-operative period. |
| 0.5 - < or =10% increase in FIO2 | Requires up to a 10% increase in FI02 to maintain oxygen saturation within prescribed range for this infant. The FI02 on which the infant returns from the OR, will be the starting baseline FIO2 for the post-operative period. |
| 0 - no increase in FIO2 | Requires no increase in FIO2 |
Consistent Pain Assessment in the Neonatal Intensive Care Unit
Sample Patient Chart Pain Scale
Consistent Pain Assessment in the Neonatal Intensive Care Unit