Adult Family Home Nurses' Association - Welcome
Non-Verbal Cues for Pain and Anxiety Assessment012ScoreBreathing Independent of VocalizationNormalOccasional labored breathingShort period of hyperventilationNoisy, labored breathingLong period of hyperventilationCheyne-Stokes respirationsNegative VocalizationsNoneOccasional moans or groansLow level speech with a negative or disapproving qualityRepeated calling outLoud moaning or groaningCryingFacial ExpressionsSmiling or inexpressiveSadFrowningFrightenedFacial grimacingBody LanguageRelaxedTenseDistressedPacingFidgetingRigidFists clenchedKnees pulled upPulling-pushing awayStriking outConsolabilityNo need to consoleDistracted orreassured by voice or touchUnable to console, distract or reassureScored Medication Guidelines: 0-3 Continue comfort meds as ordered 4-7 Give meds until score is <4; 8-10 Call MD/Hospice for orders to increase routine pain/anxiety medsThis 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 ................
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