141 lines
3.4 KiB
Markdown
141 lines
3.4 KiB
Markdown
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# Neonatal Pain, Agitation & Sedation Scale (N-PASS)
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| Form ID | FRM-SED-002 | Revision | 1.0 |
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Gestational Age | |
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| Assessment Date | |
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| Assessment Time | |
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| Assessed By | |
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## Assessment Instructions
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- Assess infant behavior over 1-2 minutes
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- Score sedation criteria first (if sedated), then pain/agitation criteria
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- Note: Premature infants may have muted responses
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## Sedation/Pain Assessment
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### 1. Crying/Irritability
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**Sedation**
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- [ ] -2: No cry with painful stimuli
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- [ ] -1: Moans/cries minimally to painful stimuli
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- [ ] 0: Appropriate crying, not irritable
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**Pain/Agitation**
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- [ ] +1: Irritable at intervals, consolable
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- [ ] +2: High-pitched or silent continuous cry, inconsolable
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### 2. Behavior/State
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**Sedation**
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- [ ] -2: No arousal to any stimuli, no spontaneous movement
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- [ ] -1: Arouses minimally to stimuli, little spontaneous movement
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- [ ] 0: Appropriate for gestational age
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**Pain/Agitation**
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- [ ] +1: Restless, squirming, awakens frequently
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- [ ] +2: Arching, kicking, constantly awake or minimal sleep
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### 3. Facial Expression
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**Sedation**
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- [ ] -2: Mouth lax, no expression
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- [ ] -1: Minimal expression with stimuli
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- [ ] 0: Relaxed, appropriate facial expression
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**Pain/Agitation**
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- [ ] +1: Any pain expression intermittent
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- [ ] +2: Any pain expression continual
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### 4. Extremities/Tone
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**Sedation**
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- [ ] -2: No grasp reflex, flaccid tone
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- [ ] -1: Weak grasp reflex, decreased tone
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- [ ] 0: Relaxed hands/feet, normal tone
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**Pain/Agitation**
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- [ ] +1: Intermittent clenched toes/fisted hands, increased tone
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- [ ] +2: Continual clenched toes/fisted hands, body tense
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### 5. Vital Signs (HR, RR, BP, SaO2)
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**Baseline Values:**
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- HR: ______ bpm
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- RR: ______ breaths/min
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- BP: ______ mmHg
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- SaO2: ______ %
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**Sedation**
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- [ ] -2: No variability with stimuli, hypoventilation or apnea
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- [ ] -1: Less than baseline variability, slow or pause in respirations
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- [ ] 0: Within baseline, no out-of-sync breathing on vent
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**Pain/Agitation**
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- [ ] +1: SaO2 76-85% with stimulation, quick return to baseline
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- [ ] +2: SaO2 ≤75% with stimulation, slow return to baseline, out-of-sync with vent
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## Total Score
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**Total N-PASS Score:** ______
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(Range: -10 to +10)
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## Score Interpretation
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- **-10 to -5**: Deep sedation
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- **-4 to -2**: Light-moderate sedation
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- **-1 to +1**: Normal sedation/pain management
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- **+2 to +5**: Mild to moderate pain/agitation
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- **+6 to +10**: Severe pain/agitation
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## Clinical Action
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### Current Sedation/Analgesia
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| Medication | Dose | Route | Frequency |
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|------------|------|-------|-----------|
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### Action Taken Based on Score
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- [ ] No change needed
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- [ ] Increase sedation/analgesia
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- [ ] Decrease sedation/analgesia
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- [ ] Notify physician
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- [ ] Non-pharmacological comfort measures
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- [ ] Other: ____________
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### Non-Pharmacological Interventions Used
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- [ ] Swaddling
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- [ ] Pacifier
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- [ ] Positioning
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- [ ] Reduced stimulation
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- [ ] Skin-to-skin care
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- [ ] Other: ____________
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### Comments
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## Signature
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| Role | Name | Signature | Date/Time |
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|------|------|-----------|-----------|
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| RN | | | |
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---
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*Form FRM-SED-002 Rev 1.0*
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**Reference:** Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol. 2008.
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