Non-Verbal Cues for Pain and Anxiety Assessment 0 1 2 Score Breathing Normal Occasional labored Noisy, labored Independent breathing breathing of period of Long period of Vocalization hyperventilation hyperventilation Cheyne-Stokes respirations Negative None Occasional moans or Repeated calling out Vocalizations groans Loud moaning or Low level speech with groaning a negative or Crying disapproving quality Facial Smiling or Sad Facial grimacing Expressions inexpressive Frowning Frightened Body Relaxed Tense Rigid Language Distressed Fists clenched Pacing Knees pulled up Fidgeting Pulling-pushing away Striking out No need to Distracted or Unable to console, console reassured by voice or distract or reassure touch Scored Medication Guidelines: 0-3 Continue comfort meds as ordered 4-7 Give meds score is <4; 8-10 Call MD/Hospice for orders to increase routine pain/anxiety meds This assessment can be used for dementia and aphasia residents or on anyone who cannot tell you what is wrong with them. Adapted from handout from Providence Hospice of Snohomish County
Non-Verbal Cues for Pain and Anxiety Assessment 0 1 2 Score Breathing Independent of Vocalization Normal Occasional labored breathing period of hyperventilation Noisy, labored breathing Long period of hyperventilation Cheyne-Stokes respirations Negative Vocalizations None Occasional moans or groans Low level speech with a negative or disapproving quality Repeated calling out Loud moaning or groaning Crying Facial Expressions Smiling or inexpressive Sad Frowning Frightened Facial grimacing Body Language Relaxed Tense Distressed Pacing Fidgeting Rigid Fists clenched Knees pulled up Pulling-pushing away Striking out No need to console Distracted or reassured by voice or touch Unable to console, distract or reassure Scored Medication Guidelines: 0-3 Continue comfort meds as ordered 4-7 Give meds score is <4; 8-10 Call MD/Hospice for orders to increase routine pain/anxiety meds This assessment can be used for dementia and aphasia residents or on anyone who cannot tell you what is wrong with them. Adapted from handout from Providence Hospice of Snohomish County
Non-Verbal%20Cues%20for%20Pain%20and%20Anxiety%20Assessment%20Tool.docx