RN Tools
Vocalization*
Whimpering, crying
Facial expression*
Tense, frowning, grimacing, frightened
Body language*
Fidgeting, rocking, guarding, withdrawn
Physiological changes*
Temp, pulse or BP elevations, diaphoresis, flushing/pallor
Physical changes*
Skin tears, pressure sores, arthritis, contractures, previous injuries
No pain
0
points
Assesses pain in patients with advanced dementia.
Addition of selected points:
|
Criteria |
Points |
|
|
Vocalization Whimpering, crying |
Absent |
0 |
|
Mild |
1 |
|
|
Moderate |
2 |
|
|
Severe |
3 |
|
|
Facial expression Tense, frowning, grimacing, frightened |
Absent |
0 |
|
Mild |
1 |
|
|
Moderate |
2 |
|
|
Severe |
3 |
|
|
Body language Fidgeting, rocking, guarding, withdrawn |
Absent |
0 |
|
Mild |
1 |
|
|
Moderate |
2 |
|
|
Severe |
3 |
|
|
Physiological changes Temp, pulse or BP elevations, diaphoresis, flushing/pallor |
Absent |
0 |
|
Mild |
1 |
|
|
Moderate |
2 |
|
|
Severe |
3 |
|
|
Physical changes Skin tears, pressure sores, arthritis, contractures, previous injuries |
Absent |
0 |
|
Mild |
1 |
|
|
Moderate |
2 |
|
|
Severe |
3 |
|
Score interpretation:
Note: all scores can be classified by type of pain: acute, chronic and acute on chronic.
Pain assessment is difficult in the dementia population, a group believed to be under-treated for pain. A standardized tool may help improve management.
Patients with severe dementia and potentially in pain.
The Abbey Pain Scale is a standardized pain assessment tool developed for use in demented nonverbal patients.
Requires a comprehensive examination to assess for physical injuries, vital signs and sources of potential pain.