nur 320 chapter 15: Pain Assessment and Management in Children
Opioid Analgesics
used to control post-operative pain + severe pain first-line analgesics - relieve pain Morphine Sulfate is considered the "Gold" standard may administer orally with effective results if dose provided is equianalgesic meperidine is generally not used with children because of the central nervous system side effects most important thing to keep in mind = can go into respiratory arrest - CNS and resp depression - look out for complications/overdose
premature infant pain profile
used to evaluate pain in preterm and full term neonates between 28 and 40 weeks' gestation
FLACC scale
used with children between 2 months and 7 years or until child can self-report higher score -> more pain
Educate Parents
teach parents how to apply topical anesthetic cream (e.g. EMLA or LMX4) tell them to apply to skin before departing for visit provide directions regarding correct placement of the cream and the importance of covering with a plastic wrap encourage parents to always follow the directions on the package regarding the amount to use
parent
the presence of the _________ is an important part of pain management children often feel more secure telling their parents about their pain and anxiety most and important and easiest intervention = have parent be there if at all possible
7-9 years (school-age) concrete operational
understands simple relationships between pain and disease understands the need for painful procedures to monitor or treat disease may associate pain with feeling bad or angry may recognize psychologic pain related to grief and hurt feelings passive resistance, clenches fists, holds body rigidly still, suffers emotional withdrawal, engages in plea bargaining can specify location and intensity of pain ---> can describe physical characteristics of pain in relation to body parts - can describe pain and locate it
School-age pain assessment tools
Faces Pain Relating Scale Oucher Scale Poker Chip Tool Word Graphic Rating Scale Visual Analogue Scale
Metabolic Changes
Increased metabolic rate with stress response - increased release of hormones - suppressed release of insulin ---> - increased fluid and electrolyte losses - altered nutritional intake - hyperglycemia
Neurologic Changes
Increased sympathetic nervous system activity and release of catecholamines: - tachycardia - elevated blood pressure - vasoconstriction - decreased tissue oxygenation - increased intracranial pressure - change in sleep patterns - irritability
Pain
Pain is whatever the patient says it is it exists whenever the patient says it exists it is an unpleasant sensory and emotional experience associated with actual or potential tissue damage pain is a personal and individual experience
pain diary
is an important tool to help record the painful episodes experienced with chronic conditions such as rheumatoid arthritis or episodic conditions such as sickle cell disease have the child choose a pain scale to record pain intensity 1 hour after intervention encourage older school-age children and adolescents with chronic pain or recurrent episodes of acute pain to keep a pain diary to describe the pain intensity, characteristics, timing, activities, and potential triggers of their pain, as well as their response to pain treatment measures a pain assessment scale should be used to rate the pain intensity before and after medications and other pain-control measures are used this record can help improve pain management when shared with healthcare providers
Answer: 1, 3, 4 Explanation: Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The child's stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a school-age, client.
1) The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation? Select all that apply. 1. Use the FLACC scale to determine the child's pain level. 2. Tell the child to ring the call bell if the leg starts hurting. 3. Administer pain medication now and continue on a regular basis. 4. Ask the child's parents to notify the nurse if the child complains of pain. 5. Use the NIPS scale to determine the child's pain level.
Answer: 4 Explanation: While all of the actions are appropriate, the nurse's initial action is to assess for external factors that might be causing pain.
13) The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate? 1. Call the healthcare provider to report increasing pain 2. Administer pain medication 3. Reposition the child in bed 4. Check to see if the cast is too tight
Answer: 2 Explanation: Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.
14) The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy is appropriate for the nurse to use decrease pain during this quick but painful procedure? 1. Swaddling 2. Sucrose pacifier 3. Massage 4. Holding the infant
Answer: 1, 2, 3, 4 Explanation: This is why the preschooler may not complain of pain. Children may not complain of pain for several reasons: young children cannot give a description of their pain because of a limited vocabulary or few pain experiences; some children believe they need to be brave and not worry their parents; preschoolers may assume the nurse knows they have pain, and some children are afraid that it will hurt more to have the pain treated.
17) The preschool-age child has been back from surgery for removal of a Wilm's tumor for 6 hours, the nurse anticipates the preschooler will need pain medication very soon. The nurse is aware that the preschool-age child may not complain of pain because Select all that apply. 1. The preschooler cannot give a description of his pain. 2. The preschooler may assume the nurse knows he has pain. 3. The preschooler may be afraid it may hurt more to have the pain treated. 4. The preschooler believes he must be brave. 5. The preschooler uses sleeping to deal with pain.
Answer: 1, 2, 3 Explanation: 1. Unrelieved pain causes physiologic consequences, such as atelectasis. 2. Unrelieved pain causes physiologic consequences, such as pneumonia. 3. Unrelieved pain causes physiologic consequences, such as ileus. 4. Unrelieved pain does not cause lethargy. Unrelieved pain causes physiologic consequences, such as alkalosis, decreased O2 saturation, atelectasis, retention of secretions, pneumonia, tachycardia, increased blood pressure, increased intracranial pressure, change in sleep patterns, irritability, fluid and electrolyte losses, altered nutritional intake, hyperglycemia, increased risk of infection, delayed wound healing, impaired GI functioning, poor nutritional intake, ileus, hyperalgesia, decreased pain threshold, and exaggerated memory of painful experiences.
18) The adolescent is 6-hours postappendectomy and refuses pain medications. The nurse would like to walk the child in the hall but is concerned that the child has unrelieved pain. The nurse knows that unrelieved pain causes physiologic consequences such as (Select all that apply.) 1. Atelectasis 2. Pneumonia 3. Ileus 4. Lethargy 5. Hypoactive bowel sounds
Answer: 2 Explanation: At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The child's behavior is appropriate for a child of this age.
7) A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate? 1. Ineffective Individual Coping Related to an Invasive Procedure 2. Anxiety Related to Anticipated Painful Procedure 3. Fear Related to the Unfamiliar Environment 4. Knowledge Deficit of the Procedure
Answer: 2 Explanation: Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.
8) A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement- based on the parent's concern? 1. Intravenous sedation 15 minutes prior to the procedure 2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure 3. Use of guided imagery during the procedure 4. Use of muscle-relaxation techniques
Answer: 2 Explanation: For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.
9) As an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure? 1. General anesthesia 2. Conscious sedation 3. Intravenous narcotics ten minutes before the procedure 4. Oral pain medication for discomfort after the procedure
Pain Transmission Gate Theory
Most common and well described Uses the analogy of a gate to describe how impulses from damaged tissues are sensed in the brain Many current pain management strategies are aimed at altering this system
Newborn/infant pain assessment tool
Neonatal Infant Pain Scale (NIPS) measures procedural pain in preterm and full-term newborns up to 6 weeks after birth what is observed: - newborn facial expression - cry quality - breathing patterns - arm and leg position - state of arousal
Pruritus is a common opioid side effect Give an antihistamine for the itching Monitor for other side effects
Nurse Adams gave her patient Jacob 4 mg of Morphine IV at 0830 for moderate to severe pain following surgery for a femur fracture His pain score was a 9/10 At 0900, Jacob begins to complain of itching all over his body. What should the nurse do?
Adolescent pain assessment tools
Oucher Scale Faces Pain Relating Scale Poker Chip Tool Word-Graphic Rating Scale Numeric Pain Scale/Visual Analogue Scale - "rate your pain on a scale of 1-10" - use ages 9 to adults Adolescent Pediatric Pain Tool
Pediatric Pain Management Discharge Teaching
dosing - provide oral syringe or dosing spoon all oral liquid medications are prescribed using the metric units or milliliters teach parents to properly dispose of remaining medications or lock them up if no longer needed check with local pharmacy or law enforcement about proper medication disposal sites
steps if child is reacting badly to opioid
if you notice that they are having a reaction to the drip, first step is to STOP the drip then give Narcan then tell provider
1-3 years (toddler)
lacks understanding of what causes pain and why it might be experienced - these are the magical thinkers and experience transductive reasoning - don't understand why pain is happening demonstrates fear of painful situations - may resist with entire body or localized withdrawal - aggressive behavior, disturbed sleep cries or wails, cannot describe intensity or type of pain uses common words for pain such as owie and boo-boo
NSAIDs
used for relief of mild to moderate pain as a general rule, aspirin is not given in pediatrics - risk of Reye's syndrome NSAIDs have analgesic, antipyretic and anti-inflammatory actions - motrin - ibuprofen ibuprofen dose is usually 5-10 mg/Kg every 6 hours (-8 hours) do not give these agents to cancer patients or those with bleeding disorders *** - may have impact on platelet activity - don't give to cancer patients, peeps bleeding probs, recent surgery pts
Faces Pain Rating Scale
usually use this starting in toddlerhood or preschool point to each face and using the words under the picture to describe the amount of pain felt then ask the child to select the face that comes closest to the amount of pain felt use the number under the selected face to score the pain
Answer: 1 Explanation: Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the child's anxiety or fear, nor can it increase the child's comfort level. The nurse can reduce anxiety or fear and increase the child's comfort level by implementing appropriate nursing interventions based on assessment scale data.
16) The nurse is working with a preschool-age client in Bryant traction for a fractured femur. Why is the Oucher Scale useful to the nurse caring for this child? 1. It provides continuity and consistency in assessing and monitoring the child's pain. 2. It decreases anxiety in the child. 3. It increases the child's comfort level. 4. It reduces the child's fear of painful procedures.
opioids
BE FAMILIAR WITH HOW/WHY THEY'RE USED AND USED ONLY WHEN THEY'RE NEEDED
Nonopioid Analgesics
BE FAMILIAR WITH THE DOSE/RANGES *********
Gastrointestinal Changes
Decreased gastric acid secretions and intestinal motility -> - impaired gastrointestinal functioning - nausea - poor nutritional intake - ileus
Preschooler pain assessment tools
Oucher Scale Faces Pain Relating Scale FLACC Body outline
Respiratory Changes
Rapid shallow breathing - alkalosis Inadequate lung expansion - decreased oxygen saturation - atelectasis Inadequate cough - retention of secretions - pneumonia
naloxone
if respiratory depression occurs due to opioid use, ____________ is administered at the rate of 1-2 mcg/kg every 1 to 2 minutes
Buzzy for Shots
is a device that uses cold and vibration stimulation to interrupt and reduce pain transmission due to immunization and venipuncture needlesticks the vibration and colorful bee distract the child start by attaching the cold pack to Buzzy and placing this on the target area - turn the buzzer on for 30 seconds then move Buzzy to an area proximal to the planned needle site, turn on the buzzer, and keep in place during the needlestick
Neuropathic Pain
result of damage or disease that affects the nerves abnormal processing of pain stimuli by the peripheral or CNS more difficult to treat i.e diabetes, cancer or limb amputation
Nociceptive Pain
result of tissue damage or injury i.e. broken bone, stub your toe, or burn your head with the flat iron
Answer: 3 Explanation: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client. NEED TO REVIEW NORMAL VITALS FOR AGE GROUPS *******
15) A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping. Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings? 1. The client is comfortable and the pain is controlled. 2. The client is in shock secondary to blood loss during surgery. 3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain. 4. The client is sleeping to avoid pain associated with surgery.
Answer: 3 Explanation: When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.
11) The nurse is caring for a child who has been sedated for a painful procedure. Which nursing activity is the priority for this child? 1. Allow parents to stay with the child. 2. Monitor pulse oximetry. 3. Assess the child's respiratory effort. 4. Place the child on a cardiac monitor.
Answer: 3 Explanation: Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.
10) A school-age client is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching? 1. "I can expect my child to have some pain for the next few days." 2. "I will plan to give my child pain medicine around the clock for the next day or so." 3. "Since my child just had surgery today, I can expect the pain level to be higher tomorrow." 4. "I will call the office tomorrow if the pain medicine is not relieving the pain."
Answer: 1, 2, 5 Explanation: A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the child's pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.
12) A young school-age client is hospitalized with a fractured femur. Which assessment tools are appropriate for this client? Select all that apply. 1. FACES pain scale 2. Oucher scale 3. Visual Analog Scale 4. CRIES Scale 5. Poker-chip tool
Answer: 1 Explanation: School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.
2) During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate? 1. Administer prescribed analgesic. 2. Ask the child's parents if they think the child is hurting. 3. Reassess the child in 15 minutes to see if the pain rating has changed. 4. Do nothing, since the child appears to be resting.
Answer: 4 Explanation: The nurse has the responsibility of relieving the child's pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the child's orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.
3) A school-age client has been receiving morphine every two hours for postoperative pain as ordered. The medication relieves the pain for approximately 90 minutes, and then the pain returns. Which action by the nurse is the most appropriate? 1. Tell the child that pain medication cannot be administered more frequently than every two hours. 2. Reposition the child and quietly leave the room. 3. Inform the parents that the child is dependent on the medication. 4. Call the healthcare provider to see if the child's orders for pain medication can be changed.
Answer: 4 Explanation: Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.
4) The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA? 1. Developmentally delayed 16-year-old, postoperative bone surgery 2. A 5-year-old, postoperative tonsillectomy 3. A 10-year-old who has a fractured femur and concussion from a bike accident 4. A 12-year-old, postoperative spinal fusion for scoliosis
Answer: 1 Explanation: Parents' presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents' presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety.
5) A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child? 1. Parents' presence at the bedside 2. Age-appropriate toys 3. Deep-breathing exercises 4. Videos for the child to watch
Answer: 1 Explanation: The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.
6) The nurse is caring for a toddler client in the postoperative period. Which pain assessment tool is most appropriate for this client? 1. FLACC Behavioral Pain Assessment Scale 2. FACES pain scale 3. Oucher scale 4. Poker-chip tool
10-15 ; 4-6 hours
Acetaminophen pediatric dose is ___________ mg/Kg every ________________
validity - accurately measures the concept it was designed to measure reliability - consistent results are obtained when measured by the same rater or other raters
After a pain assessment tool is designed, it must be evaluated for:
Use of Sedation and Analgesia
Benzodiazpines (flumazentil) Ketamine Propofol Chloral Hydrate Opioids - fentanyl (narcan is the antidote)
Immune System Changes
Depressed immune and inflammatory responses -> - increased risk of infection - delayed wound healing
Toddler pain assessment tools
Face, Legs, Activity, Cry, Consolability (FLACC) Oucher Scale Faces Pain Relating Scale
Altered Pain Response
Increased pain sensitivity -> - hyperalgesia - decreased pain threshold - exaggerated memory of painful experiences
Opioid Analgesics
Morphine Sulfate Meperidine HCL (Demerol) Dilaudid Fentanyl Oxycodone Codeine sulfate Methadone HCL (Dolophine)
Methods of administration for opioids
Oral (preferred) Subcutaneous Intramuscular Intravenous (preferred) Topical
This kid needs an antipyretic But Percocet is an opioid with Tylenol, so you can't give Tylenol again Inform the provider - I know I can't give Tylenol again, so what should I give? Recognize that you can't give Tylenol again but you need to manage this fever
Sammy is a 16 year old male with Sickle Cell Disease who was admitted to the hospital for vaso-occlusive crises. He rated his pain 7/10 at 0700 and received two Percocet tablets. At 0900, Sammy begins to complain of feeling warm, the nurse takes his temperature and he has a temperature of 101.8. What should the nurse do?
Nonpharmacological Interventions
distraction guided imagery relaxation acupuncture sucrose solution - ampule of solution - form of soothing for babies like when inserting an IV, circumcision, etc. - put it in mouth -> babies love it Hot/Cold electroanalgesia hypnosis
NIPS
Used to evaluate pain in preterm and full term neonates up to 6 weeks after birth
meperidine
an opioid that is generally not used with children because of the central nervous system side effects
aspirin
as a general rule, ___________ is not given in pediatrics risk of Reye's syndrome
pain management kit
assemble a ______________ to promote distraction, imagery, and relaxation in children include items such as magic wands, pinwheels, bubble liquid, a Slinky spring toy, a foam ball, party noisemakers, and pop-up books it may also be helpful to include items for therapeutic play such as syringes, adhesive bandages, alcohol swabs, and other supplies from a medical kit the pain management kit may be especially helpful for distracting children who are being prepared for medical procedures parents can use this kit to help their kid cope and choose items out of the kit that fit their child's developmental stage and personal interests
Combination Products
common practice to combine opioids and nonnarcotic analgesics into a single tablet or capsule the 2 classes of analgesics work synergistically to relieve pain - dose of opioid may be reduced examples of combination analgesics include: Percocet - oxycodone hydrochloride, 7.5 mg - acetaminophen, 500 mg Tylenol with Codeine - single dose may contain from 15-60 mg codeine - and 300-1,000 mg acetaminophen
10-12 years (school-age) transitional
better understanding of the relationship between an event and pain has a more complex awareness of physical and psychologic pain -> such as moral dilemmas and mental pain may pretend comfort to project bravery, may regress with stress and anxiety able to describe intensity and location with more characteristics able to describe psychologic pain
Characteristic neonatal pain facial expressions include
bulged brow eyes squeezed shut furrowed nasolabial creases open lips pursed lips stretched mouth taut tongue quivering chin
Developing Cultural Competency = Codeine use
codeine is converted in the liver as morphine approx 10% of Caucasians and some other ethic groups are unable to convert codeine to morphine because they lack the CYP2D6 enzyme due to these genetic differences, these individuals may have limited analgesia or no response at all this reinforces the importance of proper pain management monitoring
Tylenol with Codeine
combination analgesic that includes: - from 15-60 mg codeine - from 300-1,000 mg acetaminophen
Percocet
combination analgesic that includes: - oxycodone hydrochloride, 7.5 mg - acetaminophen, 500 mg
13-18 years (adolescent) formal operational
has a capacity for sophisticated and complex understanding of the causes of physical and mental pain recognizes that pain has both qualitative and quantitative characteristics can relate to the pain experienced by others wants to behave in a socially acceptable manner, shows a controlled behavioral response - may immerse self in an activity as a pain distraction may not complain about pain if given cues that nurses and other healthcare providers believe it should be tolerated more sophisticated descriptions as experience is gained may think nurses are in tune with their thoughts, so they do not need to tell the nurse about their pain
6-12 months (infant)
has a pain memory -> responsive to parental anxiety reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritability, restlessness cries
0-6 months (infant)
has no understanding of pain -> is responsive to parental anxiety generalized body movements, chin quivering, facial grimacing, poor feeding cries
5-10 ; 6-8 hours
ibuprofen dose is usually __________ mg/Kg every ___________
Morphine Sulfate
is considered the "Gold" standard of pain relief
Factors Influencing Pain
maturation of the nervous system child's developmental stage previous pain experience temperament
Anesthetizing cream (e.g., L-M-X4 or EMLA)
may be prescribed for use prior to a painful needlestick apply a thin layer on selected sites and wait 30 seconds, and then apply a thick layer of cream over intact skin cover the cream with plastic wrap or a transparent adhesive dressing to keep the cream in place and to prevent ingestion depending on the cream used, the dermal surface is anesthetized in 30 to 60 minutes
Sedation
medically controlled state of depressed consciousness (light to deep) used for painful procedures moderate sedation (formerly "conscious sedation") - low doses of sedatives are given - child is able to maintain protective reflexes (cough and gag) - patent airway deep sedation - depressed consciousness or unconsciousness -> in which protective reflexes are lost - airway may not be maintained! ******
Acetaminophen
most widely prescribed drug in pediatrics nonopioid analgesic usual pediatric dose is 10-15 mg/Kg every 4-6 hours analgesic and antipyretic properties only, often used in combination products with opioids
1-2 ; 1 to 2 minutes
naloxone is administered at the rate of _______ mcg/kg every ________________
Safety First ******* KNOW THIS INFO FROM SLIDE
narcotics are second witness medications to promote patient safety **** - need to be double-checked by another nurse all patients often respond differently most major life-threatening complication of opioid administration = respiratory depression **** ---> if this occurs: - naloxone is administered at the rate of 1 -2 mcg/kg every 1 to 2 minutes monitor the child for respiratory depression because naloxone has a shorter half life than opioids
Patient Controlled Analgesia (PCA)
often utilized for post-op patients safe method to administer pain medication requires a special PCA pump that is programmed to deliver the ordered amount safety features in the pump prevent over-usage controlled by the patient - usually children > 7 years - may use in younger kids as young as 5 if they understand the concept most institutions do not allow parents to administer PCA
Pediatric Pain Pearls* ****** KNOW THIS INFO FROM SLIDE
pain assessment is considered the 5th vital sign guidelines are available regarding when you should treat pain morphine = gold standard naloxone is the reversal agent for the opioid agents be consistent with using the same pain scale - must be appropriate for age and developmental level IV narcotics are second witness medications at most institutions
3-6 years (preschool) preoperational
pain is a hurt does not relate pain to illness may relate pain to an injury ---> often believes pain is punishment or someone else is responsible for the pain - still operates on transductive reasoning unable to understand why a painful procedure will help them feel better active physical resistance, directed aggressive behavior, strikes out physically and verbally when hurt, easily frustrated has the language skills to express pain on a sensory level can identify location and intensity of pain, may deny pain, may believe their pain is obvious to others
Pain Assessment Scales
pain scales must be appropriate for the child's age and development level self-report scale = gold standard children as young as 3 are able to report location and degree of pain vital signs are not are reliable tool of pain in children higher score -> more that neonate is exhibiting pain
Cultural Influences on Pain
pain sensitivity is thought to vary by race and ethnicity culture and social learning greatly influence the child's perception of pain what differences do you expect to see demonstrated? Blacks and Latinos? - perceive greater pain than Whites Irish, Japanese, Russian, Amish - encourage a stoic response with a diminished expression of pain Puerto Rican, Jewish, and Arabic - more likely to use both verbal and nonverbal methods (moans and groans) to express pain freely
Chronic pain
persistent or recurring lasting longer than 3 months difficult to treat
Oucher Scale
presents a series of 6 photos of a child expressing increasing pain intensity in combination with a vertical Visual Analog Scale the tool has been developed and tested in 4 cultural groups: White, African American, Hispanic, and Asian use the scale with the best match for the child's ethnicity point to each photograph and explain that the bottom picture is "no hurt," the second picture is a "little hurt," the third picture is "a little more hurt," and so on until the sixth picture which is the "biggest or most hurt you could ever have" the young child selects a face that matches the level of pain the numbers beside the photos are used to score the amount of pain the child reports the older child can select a pain intensity number between 0 and 10 the nurse should NOT compare the photos with the child's expression to determine a pain level *
Opioid Agents Side Effects
respiratory depression - respiratory is shut down from opioid use - lose respiratory drive sedation N/V constipation urinary retention pruritus
Acute pain
sudden in onset associated with single event usually subsides once treated
Techniques to Increase Comfort
vapocoolant spray - can be used for injections - spray the site or soak a cotton ball and apply to intact skin for about a minute EMLA cream - emulsion of 2.5% lidocaine and 2.5% prilocaine - effective if applied 60 minutes before a needlestick, venipuncture, or circumcision procedure on intact skin in infants and children - topical anesthetic cream - helps accessing be less painful - sometimes before IM injections and shit L-M-X4 - liposomal lidocaine - is effective if applied 30 minutes before a needlestick - available without a prescription - topical anesthetic cream Synera patch - anesthetic patch - contains 70 mg of lidocaine and 70 mg of tetracaine - can be applied to intact skin for 20 to 30 minutes prior to a procedure - becomes heated on application and results in more rapid anesthesia Buzzy for Shots - a device that has a cold pad placed against the skin and a buzzing bee that vibrates - Buzzy is placed over the site of a needlestick for 30 seconds and then moved and placed proximally during the needlestick - the cold and vibration stimulation interferes with pain transmission - provides distraction J-Tip - a needle-free powder lidocaine delivery system produces rapid analgesia (within 1 to 3 minutes) for IV starts and venipuncture - has a sterile, single-use, prefilled, and disposable cartridge that is pressed against the skin - pressurized CO2 gas ruptures the cartridge and forces lidocaine particles to penetrate the skin - prepare the child for the small pop sound when it is used LET - (lidocaine, epinephrine, and tetracaine) - a topical anesthetic for laceration repair - LET liquid is applied to a cotton ball and the skin - LET gel is applied to the skin and covered with an occlusive dressing - works in 30 minutes
Misconceptions About Pain in Children
years ago, healthcare providers believed infants and children did not feel pain children were once grossly under treated for pain in the United States it is now recognized that infants and children do feel pain just like adults do pain transmission develops during the third trimester children use distraction to cope with pain but eventually become exhausted and fall asleep
Words Used By Small Children to Describe Pain
young children are unable to give a detailed description of their pain due to their limited vocabulary words used to indicate pain include owie, boo-boo, hot, tight, ache, etc
Chapter 15- Pain Assessment & Management
· Types of pain · Factors influencing pain · Kids understanding of pain (development) · Pain assessment and pain scales · Gold standard for sedation · Opioid side effects- most worrisome effects (think ABC!!!) · Atraumatic care- methods to reduce pain before/during procedures · Reversal agents and dosages · Acetaminophen and & ibuprofen recommended doses · Slide 49 · Slide 66
