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The gold standard for pain assessment is the patient's report, and attempts to obtain a report using tools such as the 0-to-10 pain-rating scale are recommended.1-3 But many patients can't report pain for any of a variety of reasons. For these patients, behavioral indicators, such as facial expressions and changes in activity, are used to assess for the presence of pain.2, 3


In a recent study, nurses were asked to assess pain in 22 preterm neonates on mechanical ventilation whom they had not cared for before.4 The nurses were asked to identify whether the infant was receiving placebo or morphine. The nurses considered a variety of indicators, including response to care, physiologic indicators, and posture, during their assessment. They were able to identify the infants receiving placebo 71% of the time. The most common indicators seen in the infants who received placebo-and presumably were in the most pain-were facial expressions of pain, high activity levels, poor response to handling, and poor synchrony with the ventilator.


It's important to remember that behavioral indicators may be helpful in determining the presence of pain, but no research shows that certain behaviors represent a particular pain intensity: if a patient cannot provide a report of the pain intensity, the pain intensity is unknown.3 When caring for a patient of any age who can't report her or his pain level, consider the underlying pathology, such as surgery, trauma, or a known painful activity. Assumptions can be made on that basis, and the acronym APP (assume pain present) can be documented.3


If the underlying pathology or behaviors suggest that pain may be present and analgesia is not already being administered, initiate an analgesic trial at the recommended starting dose.2, 3 Administer a nonopioid, such as acetaminophen (Tylenol) or a nonsteroidal antiinflammatory drug, when pain is thought to be mild, and give an opioid when pain seems more severe. Adjust the treatment plan according to the patient's response to the trial. For example, if pain seems to be persistent, schedule around-the-clock doses or administer a continuous infusion. Finally, give analgesia before performing procedures that are known to be painful, such as turning and endotracheal suctioning.3


According to this study:


* Preterm infants on mechanical ventilation who were given morphine showed a significant reduction in behavioral indicators of pain.


Section Description

This month's Pain Control deals with different aspects of pain treatment in newborns. One part is a discussion of the effects of breastfeeding and breast milk on pain in neonates; the second part discusses a study on pain assessment in the neonate.




1. American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain. 5th ed. Glenview, IL: The Society; 2003. [Context Link]


2. Herr K, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs 2006;7(2):44-52. [Context Link]


3. Pasero C, McCaffery M. No self-report means no pain-intensity rating. Am J Nurs 2005;105(10):50-3. [Context Link]


4. Boyle EM, et al. Assessment of persistent pain or distress and adequacy of analgesia in preterm ventilated infants. Pain 2006;124(1-2):87-91. [Context Link]