The Individualized Numeric Rating Scale (INRS)
The Individualized Numeric Rating Scale (INRS) for assessment of pain in nonverbal children
The Individualized Numeric Rating Scale (INRS) was developed by Martha A.Q. Curley, R.N., Ph.D. in collaboration with Jean C. Solodiuk, RN PhD (Pain Treatment Service, Children's Hospital Boston).
The Individualized Numeric Rating Scale (INRS) was developed by Martha A.Q. Curley, R.N., Ph.D. in collaboration with Jean C. Solodiuk, RN PhD (Pain Treatment Service, Children's Hospital Boston).
Permission to use the Individualized Numeric Rating Scale (INRS)
You are free to reproduce and use the Individualized Numeric Rating Scale (INRS) for research or clinical practice. The INRS may be reproduced on forms with hospital or clinical unit letterhead or logos, or used in electronic record systems. Please cite: Solodiuk, J., & Curley, M. A. Q. (2003). Evidence based practice: Pain assessment in nonverbal children with severe cognitive impairments – The Individualized Numeric Rating Scale (INRS). Journal of Pediatric Nursing, 18(4), 295-299.
The Individualized Numeric Rating Scale (INRS), may not be used for commercial purposes or monetized without the express written permission from Dr. Martha A.Q. Curley. If you would like to republish the tool in any form external to your organization, you will have to obtain permission from Dr. Martha A.Q. Curley. Permission requests should be made in writing to Dr. Curley: MAQCurley@gmail.com.
Requests to translate the Individualized Numeric Rating Scale (INRS), into another language should be made in writing to Dr. Curley: MAQCurley@gmail.com. Forward and back translations must be certified for accuracy. Any translations must be made freely available for research or clinical practice. Translations may not be used for commercial purposes or monetized without the written permission from Dr. Martha A.Q. Curley.
The Individualized Numeric Rating Scale (INRS), may not be used for commercial purposes or monetized without the express written permission from Dr. Martha A.Q. Curley. If you would like to republish the tool in any form external to your organization, you will have to obtain permission from Dr. Martha A.Q. Curley. Permission requests should be made in writing to Dr. Curley: MAQCurley@gmail.com.
Requests to translate the Individualized Numeric Rating Scale (INRS), into another language should be made in writing to Dr. Curley: MAQCurley@gmail.com. Forward and back translations must be certified for accuracy. Any translations must be made freely available for research or clinical practice. Translations may not be used for commercial purposes or monetized without the written permission from Dr. Martha A.Q. Curley.
Individualized NRS Guidelines
Description:
The Individualized NRS is a numerical rating scale that includes space for the parent or nurse to insert typical pain responses for a nonverbal individual patient with cognitive impairment. Although these patients may appear insensitive to pain, they may be unable to communicate their pain, or caregivers may be unable to recognize their responses to pain.
The iNRS can be used for all children who are nonverbal, for example, intubated critically ill pediatric patients.
Assessment Method:
The INRS is a 0-10 numeric rating scale individualized to the patient. Building upon the NRS (numerical rating scale in which numbers ranging from 0 to 10 are placed at equidistant points on a line where 0 equals no pain and 10 equals the worst pain imaginable), the nurse or parent can use the FLACC acronym to populate patient pain behaviors on the vertical line that corresponds to pain intensity.
Instructions:
1. Think about the child’s painful events. How does the child act when in mild, moderate or severe pain?
2. In the diagram, write in the child‘s typical pain behaviors on the line that corresponds to its pain intensity where 0 = no pain and 10 = worst possible pain.
3. When describing the child’s pain, think about changes in:
Facial expression: Squinting eyes, frowning, distorted face, grinds teeth, thrusts tongue
Leg or general body movements: tense, gestures (more or less) or touches part of body that hurts
Activity, or social interaction: Not cooperative, cranky, irritable, unhappy; not moving, less active, quiet or more active, fidgety,
Cry or vocalization: Moaning, whimpering, crying, yelling
Consolability: Less interaction, seeks comfort or physical closeness, difficult to distract/satisfy
Other changes: Tears, sweating, holds breath, gasping. For example parents may tell you that when their child is in moderate pain he/ she may become irritable or cranky. So fill in the blank under moderate pain with irritable or cranky.
The Individualized NRS is a numerical rating scale that includes space for the parent or nurse to insert typical pain responses for a nonverbal individual patient with cognitive impairment. Although these patients may appear insensitive to pain, they may be unable to communicate their pain, or caregivers may be unable to recognize their responses to pain.
The iNRS can be used for all children who are nonverbal, for example, intubated critically ill pediatric patients.
Assessment Method:
The INRS is a 0-10 numeric rating scale individualized to the patient. Building upon the NRS (numerical rating scale in which numbers ranging from 0 to 10 are placed at equidistant points on a line where 0 equals no pain and 10 equals the worst pain imaginable), the nurse or parent can use the FLACC acronym to populate patient pain behaviors on the vertical line that corresponds to pain intensity.
Instructions:
1. Think about the child’s painful events. How does the child act when in mild, moderate or severe pain?
2. In the diagram, write in the child‘s typical pain behaviors on the line that corresponds to its pain intensity where 0 = no pain and 10 = worst possible pain.
3. When describing the child’s pain, think about changes in:
Facial expression: Squinting eyes, frowning, distorted face, grinds teeth, thrusts tongue
Leg or general body movements: tense, gestures (more or less) or touches part of body that hurts
Activity, or social interaction: Not cooperative, cranky, irritable, unhappy; not moving, less active, quiet or more active, fidgety,
Cry or vocalization: Moaning, whimpering, crying, yelling
Consolability: Less interaction, seeks comfort or physical closeness, difficult to distract/satisfy
Other changes: Tears, sweating, holds breath, gasping. For example parents may tell you that when their child is in moderate pain he/ she may become irritable or cranky. So fill in the blank under moderate pain with irritable or cranky.
Scoring Method:
Observers note behaviors exhibited and associate them with the Individualized NRS to estimate pain intensity. Additional adjectives may be added at any time by other members of the team. Pain is scored and documented according to the noted behaviors that have been indicated on the patient’s Individualized NRS. For example:
Observers note behaviors exhibited and associate them with the Individualized NRS to estimate pain intensity. Additional adjectives may be added at any time by other members of the team. Pain is scored and documented according to the noted behaviors that have been indicated on the patient’s Individualized NRS. For example:
Articles of Interest
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Solodiuk, J.C., Scott-Sutherland, J., Meyers, M., Myette, B., Shusterman, C.,. Karian, V.E., Harris, S.K., Curley, M.A.Q. (2010). Validation of the Individualized Numeric Rating Scale (INRS): A pain assessment tool for nonverbal children with intellectual disability. Pain, 150(2), 231–236 (PMID: 20363075)
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Solodiuk, J., & Curley, M. A. Q. (2003). Evidenced based practice: Pain assessment in nonverbal children with severe cognitive impairments – The Individualized Numeric Rating Scale (INRS). Journal of Pediatric Nursing, 18(4), 295-299. (PMID: 12923744)
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