# Neonatal Pain, Agitation & Sedation Scale (N-PASS)

| Form ID | FRM-SED-002 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Gestational Age | |
| Assessment Date | |
| Assessment Time | |
| Assessed By | |

## Assessment Instructions

- Assess infant behavior over 1-2 minutes
- Score sedation criteria first (if sedated), then pain/agitation criteria
- Note: Premature infants may have muted responses

## Sedation/Pain Assessment

### 1. Crying/Irritability

**Sedation**
- [ ] -2: No cry with painful stimuli
- [ ] -1: Moans/cries minimally to painful stimuli
- [ ] 0: Appropriate crying, not irritable

**Pain/Agitation**
- [ ] +1: Irritable at intervals, consolable
- [ ] +2: High-pitched or silent continuous cry, inconsolable

### 2. Behavior/State

**Sedation**
- [ ] -2: No arousal to any stimuli, no spontaneous movement
- [ ] -1: Arouses minimally to stimuli, little spontaneous movement
- [ ] 0: Appropriate for gestational age

**Pain/Agitation**
- [ ] +1: Restless, squirming, awakens frequently
- [ ] +2: Arching, kicking, constantly awake or minimal sleep

### 3. Facial Expression

**Sedation**
- [ ] -2: Mouth lax, no expression
- [ ] -1: Minimal expression with stimuli
- [ ] 0: Relaxed, appropriate facial expression

**Pain/Agitation**
- [ ] +1: Any pain expression intermittent
- [ ] +2: Any pain expression continual

### 4. Extremities/Tone

**Sedation**
- [ ] -2: No grasp reflex, flaccid tone
- [ ] -1: Weak grasp reflex, decreased tone
- [ ] 0: Relaxed hands/feet, normal tone

**Pain/Agitation**
- [ ] +1: Intermittent clenched toes/fisted hands, increased tone
- [ ] +2: Continual clenched toes/fisted hands, body tense

### 5. Vital Signs (HR, RR, BP, SaO2)

**Baseline Values:**
- HR: ______ bpm
- RR: ______ breaths/min
- BP: ______ mmHg
- SaO2: ______ %

**Sedation**
- [ ] -2: No variability with stimuli, hypoventilation or apnea
- [ ] -1: Less than baseline variability, slow or pause in respirations
- [ ] 0: Within baseline, no out-of-sync breathing on vent

**Pain/Agitation**
- [ ] +1: SaO2 76-85% with stimulation, quick return to baseline
- [ ] +2: SaO2 ≤75% with stimulation, slow return to baseline, out-of-sync with vent

## Total Score

**Total N-PASS Score:** ______

(Range: -10 to +10)

## Score Interpretation

- **-10 to -5**: Deep sedation
- **-4 to -2**: Light-moderate sedation
- **-1 to +1**: Normal sedation/pain management
- **+2 to +5**: Mild to moderate pain/agitation
- **+6 to +10**: Severe pain/agitation

## Clinical Action

### Current Sedation/Analgesia
| Medication | Dose | Route | Frequency |
|------------|------|-------|-----------|
| | | | |
| | | | |

### Action Taken Based on Score
- [ ] No change needed
- [ ] Increase sedation/analgesia
- [ ] Decrease sedation/analgesia
- [ ] Notify physician
- [ ] Non-pharmacological comfort measures
- [ ] Other: ____________

### Non-Pharmacological Interventions Used
- [ ] Swaddling
- [ ] Pacifier
- [ ] Positioning
- [ ] Reduced stimulation
- [ ] Skin-to-skin care
- [ ] Other: ____________

### Comments



## Signature

| Role | Name | Signature | Date/Time |
|------|------|-----------|-----------|
| RN | | | |

---

*Form FRM-SED-002 Rev 1.0*

**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.