Assessing Pain in the Nonverbal or Cognitively Impaired 3rd Ed, 9/09

ADULTS
Themostaccurateandreliableevidenceofthepresenceandintensityofpainisthepatientsselfreport.
Evenpatientswithmildtomoderatecognitiveimpairmentmaybeabletousepainintensityscales(e.g.,
010,mildmoderatesevere).Forpatientsunabletoreportpain,screenforthepresenceofpainby
observingbehaviorsandwatchingforchangesinfunction(e.g.,changesingait,withdrawnoragitated
behavior,moaning,groaning,andcrying).UWHealthrecommendsthefollowinginstrumentasan
optiontoassessanddocumentpaininanadultwithcognitiveimpairment.

ChecklistofNonverbalPainIndicators(CNPI)
With Rest
Movement
1. Vocalcomplaints:Nonverbal
(Expressionofpain,notinwords,moans,groans,grunts,cries,gasps,sighs)
2. FacialGrimaces/Winces
(Furrowedbrow,narrowedeyes,tightenedlips,jawdrop,clenchedteeth,
distortedexpressions)
3. Bracing
(Clutchingorholdingontosiderails,bed,traytable,oraffectedareasduring
movement)
4. Restlessness
(Constantorintermittentshiftingofposition,rocking,intermittentorconstant
handmotions,inabilitytokeepstill)
5. Rubbing
(Massagingtheaffectedarea)
6. Vocalcomplaints:Verbal
(Wordsexpressingdiscomfortorpain,ouch,thathurts,cursingduring
movement,orexclamationsofprotest:stop,thatsenough
SubtotalScores
TotalScore

TheCNPIisdesignedtomeasurepainbehaviorsincognitivelyimpairedelders.Thetoolincludessixpain
behavioralitemscommonlyobservedinolderadultsincludingnonverbalvocalizations,facialgrimacing
orwincing,bracing,rubbing,restlessness,vocalcomplaints.Eachitemisscoredonadichotomousscale
(1=present,0=notpresent,bothatrestandonmovement,forapossiblerangeofscoresfrom0to6
pointsforeachsituationandatotalof12points.ItisimportanttonotethataCNPIscoreisnot
equivalenttoapainintensityrating.Nointerpretationoftotalscoreisprovided,butchangesinthe
scoreovertimemaybehelpfultoevaluateefficacyofinterventions.

Likemanyaspectsofpainmanagementanindividualizedapproachshouldbeutilized.Involvethefamily
ifpossibletoidentifyspecificbehaviorsintheirfamilymemberthatmayindicatepain.Observeand
documentbehaviorsandresponsetoanalgesicsandcomfortmeasures.Anindepthcritiqueofthe
existingnonverbalpainassessmenttoolsaswellascopiesoftools(whenavailable)orcontact
informationforaccessingispostedattheCityofHopewebsitewww.cityofhope.org/prc/elderly.asp
[listedunderElderlysection,Guidelinesandpathways,item#5].

1
Pain Fast Facts: PainFastFact:AssessingPainintheNonverbalorCognitivelyImpaired
continued

CHILDREN
UsetheUWChildrensHospitalPainScaleforPreverbalandNonverbalChildrendevelopedandtested
onpreverbalchildren(lessthan3yearsold)andcognitivelyimpairedchildrentoassesspain.

ThisinstrumentisforpediatricpatientsandisNOTappropriateforadults.

References
SoetengaD,FrankJ,PellinoTA.AssessmentofthevalidityandreliabilityoftheUniversityofWisconsinChildrens
HospitalPainscaleforPreverbalandNonverbalChildren.PediatricNursing1999;25(6):670676.
Feldt,KS.ChecklistofNonverbalPainIndicators.PainManagementNursing2000;1(1):1321.
HerrKetal.Toolsforassessmentofpaininnonverbalolderadultswithdementia:astateofthesciencereview.
JournalofPainandSymptomManagement2006;31(2):170192.

Permissiongrantedtomodifyoradaptprovidedwrittencreditisgiventothe 2
UniversityofWisconsinHospital&Clinics,Madison,WI
Internet:Visitwww.uwhealth.org/pain
Intranet:MoreFastFactsinUConnectunderClinicalGuidelines/PainManagementResources