Newborn Measurement guide

• The nurse uses the CRIES pain assessment scale, which includes:

C – Crying:

• No crying = 0
• Crying with a high-pitched tone = 1
• Crying with inability to console or stop crying = 2

R – Requires Oxygen (if oxygen saturation < 95%):

• Does not require oxygen = 0
• Requires less than 30% oxygen = 1
• Requires more than 30% oxygen = 2

I – Increased Vital Signs:

• Heart rate and blood pressure within normal limits = 0
• Heart rate and blood pressure elevated but less than 20% above normal = 1
• Heart rate and blood pressure more than 20% above normal = 2

E – Expression:

• Normal facial expression = 0
• Grimacing facial expression = 1
• Grimacing with labored/noisy breathing = 2

S – Sleeplessness:

• Regular sleep pattern = 0
• Awakens frequently = 1
• Continuously awake = 2
• The nurse informs the physician of the pain score if it is greater than 3.
• The physician prescribes pharmacological pain management if the pain score is greater than 5.

Children from 3 Months to 6 Years of Age:

• The nurse uses the FLACC Scale, which includes:
• Facial expression
• Leg movement
• Activity
• Crying
• Consolability
• The nurse informs the physician of the pain score if it is greater than 3.

Children from Birth to 3 Months (CRIES Scale):

• Crying: (No crying – High-pitched crying – Inconsolable crying)
• Requires Oxygen if SpO₂ < 95%: (No – Requires < 30% oxygen – Requires > 30% oxygen)
• Increased Vital Signs:
• No change or below normal heart rate and blood pressure
• Increase in heart rate and blood pressure ≤ 20% above normal
• Increase in heart rate and blood pressure > 20% above normal
• Expression: (None – Grimacing – Grimacing with moaning)
• Sleeplessness: (No – Awakens frequently – Continuously awake)

• The nurse documents the pain assessment in the Pain Assessment Form.

C. Frequency of Pain Reassessment:

1. Pain is reassessed to determine the patient’s response to the established treatment plan.
2. The nurse reassesses and documents pain in the same form as follows:
• Every shift
• When the patient reports pain
• Before surgery
• After surgery
• One hour after administration of pain medication
• As per physician’s orders

D. Pain Management Protocols:

3. Pain Management:

• The attending physician establishes a pain management plan according to the pain management protocol, documents it in the clinical physician notes, and writes the orders in the physician order sheet.
• The nurse records the treatment plan in the Pain Assessment Form in the designated area.
• The assigned nurse implements and follows up the treatment plan according to the pain management form and physician instructions.

4. Education of Parents/Guardians of Newborns:

• Information is provided regarding:
• Methods of pain assessment and available treatment options
• Comprehensive medication list (dose – frequency – route of administration)
• Therapeutic effects and potential side effects

5. Discharge Plan:

• All discharged patients are provided with a pain management treatment plan.