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Pain assessment instruments do not replace clinical judgment. They are used as one part of the assessment to help determine a neonate’s level of pain.
Both behavioral and physiologic pain indicators may be decreased or absent in certain neonates (e.g., those who are neurologically impaired, extremely premature, or on neuromuscular blocking agents).
All neonates experience pain and therefore require pain prevention or management. High-risk preterm and medically unstable neonates are subjected to multiple painful procedures while in the neonatal intensive care unit (NICU) because of their physiologic variability and disease processes. Their care frequently requires painful procedures (e.g., heel sticks; peripheral venous lines; nasal, oral, and tracheal suctioning; arterial lines; endotracheal intubation; chest tubes; lumbar punctures).
A thorough assessment of pain includes both physiologic and behavioral cues.undefined#ref1">1 Physiologic pain cues may include changes in heart rate, respiratory rate, oxygen saturation, and blood pressure. Behavioral pain cues may include altered facial expressions, change in activity level, agitation, and crying.2 Extremely immature, fragile neonates and chronically ill neonates who have been exposed to repeated painful experiences have difficulty generating a pain response. Caution should be taken not to interpret this response as an indication that the neonate is not in pain.
Many different pain assessment instruments are available. Pain assessment instruments should be chosen based on reliability and validity testing, neonatal population and developmental age, and ease of use.2
One reliable and valid instrument available for the preterm neonate is the Premature Infant Pain Profile (PIPP).2 This instrument has been used to assess procedural as well as surgical pain, has been repeatedly validated, and is unique because it includes contextual (gestational age), physiologic, and behavioral states.2
Pain management is multimodal and consists of pharmacologic and nonpharmacologic interventions. Nonpharmacologic interventions include thoughtful planning of care, prevention of pain, and behavioral measures. Planning of care involves the clustering of interventions to allow the neonate adequate rest periods. Prevention measures include reducing the total number of painful procedures the neonate is exposed to by evaluating all aspects of care, such as minimizing tape and adhesives on the skin as much as possible, grouping laboratory tests and diagnostic procedures, ensuring premedication before painful procedures, and avoiding performing painful procedures and routine care at the same time. For example if the diaper is changed while removing tape from the skin, the neonate may begin to perceive the diaper change as a painful procedure.2 Facilitated tucking, swaddling, nonnutritive sucking or breastfeeding, skin-to-skin care, and oral sucrose administration are all examples of nonpharmacologic interventions to reduce pain in the neonate.2
Pharmacologic approaches to pain management should be used when moderate, severe, or prolonged pain is assessed or anticipated. Adverse effects of pain medication must be considered when managing pain in the neonate. Pharmacologic approaches to analgesia include the use of opioids, nonopioid analgesia, and topical therapy. When sedatives or neuromuscular blocking agents are used, the neonate’s pain must be managed proactively because these medications suppress the behavioral expression of pain, but do not treat it.2
Untreated or undertreated pain may cause both short- and long-term adverse consequences. Short-term consequences may include increased heart rate, increased oxygen requirements, and oxygen desaturation.2 Long-term consequences may include depressed immune response; and altered neurodevelopmental, social, and emotional function.2
Rationale: Developmental maturity, illness severity, and sleep states may cause the neonate to have a subtle reaction to pain.
Cluster painful procedures together throughout the day to minimize the neonate’s daily painful experiences.2
Rationale: Although vital signs are not specific to pain alone, baseline measurements of vital signs, oxygen usage, and oxygen saturation are helpful because these parameters may increase or decrease based on the neonate’s individual response to pain.
A valid pain assessment tool is not available for neonates receiving a neuromuscular blocking agent. Assume pain is present and provide analgesic measures.
Be aware that pain scores should return to the preprocedure baseline after a painful procedure. If pain scores do not return to baseline, follow up with nonpharmacologic and pharmacologic interventions as needed and as ordered, then reassess the neonate for pain. If the neonate remains in pain, notify the practitioner.
Rationale: Changes in the neonate’s vital signs may indicate that he or she is in pain.
Notify the practitioner of bradycardia, tachycardia, increased temperature, apnea, and desaturation.
Rationale: Periods of calm and adequate sleep result in improved weight gain and duration of rapid eye movement sleep. The ability to self-calm promotes self-regulation and tolerance of painful procedures.
Notify the practitioner of the neonate’s need for extended time to recover after painful procedures and of poor weight gain.
Coughlin, M.E. (2017). Chapter 6: Guidelines for pain and stress prevention, assessment, management, and the family. In Trauma-informed care in the NICU: Evidence-based practice guideline for neonatal clinicians (pp. 101-136). New York: Springer Publishing Company.
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