Pain Assessment Tools
Neonatal/Infant Pain Scale (NIPS)
(Recommended for children less than 1 year old) - A score greater than 3 indicates pain
|
Pain Assessment |
Score |
|
Facial Expression |
|
|
|
0 Ð Relaxed muscles |
Restful face, neutral
expression |
|
|
1 Ð Grimace |
Tight facial muscles;
furrowed brow, chin, jaw, (negative facial expression Ð nose, mouth and brow) |
|
Cry |
|
|
|
0 Ð No Cry |
Quiet, not crying |
|
|
1 Ð Whimper |
Mild moaning, intermittent |
|
|
2 Ð Vigorous Cry |
Loud scream; rising, shrill,
continuous (Note: Silent cry may be scored if baby is intubated as evidenced
by obvious mouth and facial movement. |
|
Breathing Patterns |
|
|
|
0 Ð Relaxed |
Usual pattern for this
infant |
|
|
1 Ð Change in Breathing |
Indrawing, irregular, faster
than usual; gagging; breath holding |
|
Arms |
|
|
|
0 Ð Relaxed/Restrained |
No muscular rigidity;
occasional random movements of arms |
|
|
1 Ð Flexed/Extended |
Tense, straight legs; rigid
and/or rapid extension, flexion |
|
Legs |
|
|
|
0 Ð Relaxed/Restrained |
No muscular rigidity;
occasional random leg movement |
|
|
1 Ð Flexed/Extended |
Tense, straight legs; rigid
and/or rapid extension, flexion |
|
State of Arousal |
|
|
|
0 Ð Sleeping/Awake |
Quiet, peaceful sleeping or
alert random leg movement |
|
|
1 Ð Fussy |
Alert, restless, and
thrashing |
|
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Pages created and maintained
by Sara Faulds and James
Moore, MD
Last Updated:
September 4, 2007