nicu-picu/Forms/Sedation-Scoring/FRM-SED-002-NPASS-Scale.md

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

Form ID	FRM-SED-002	Revision	1.0

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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

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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.