Chapter 36: Pain Management in Children

CRIES Scale for Neonatal Postoperative Pain Assessment

A behavioral assessment tool that also includes measures of physiologic parameters It was developed to quantify postoperative pain in the newborn. The tool also may be used to monitor the infant's progress over time during recovery or after interventions. The tool assesses five parameters: cry, oxygen required for saturation levels less than 95%, increased vital signs, facial expression, and sleeplessness Each parameter is scored as 0, 1, or 2 and then totaled. As with other assessment tools, the higher the score, the greater the infant's pain.

FLACC Behavioral Scale for pain in nonverbal young children and children with cognitive impairment

A behavioral assessment tool that is useful in assessing a child's pain when the child cannot report accurately his or her level of pain It has been demonstrated to be a reliable tool for children from age 2 months to 7 years of age This tool measures five parameters: facial expression, legs, activity, cry, and consolability Observe the child with the legs and body uncovered. If the child is awake, observe him or her for 1 to 2 minutes; if sleeping, observe the child for 2 minutes or longer. Each parameter is scored as 0, 1, or 2. The scores are totaled, with a maximum achievable score of 10. As with other assessment tools, the higher the score, the greater the pain.

Riley Infant Pain Scale (RIPS)

A behavioral assessment tool useful for infants who lack verbal ability Measures six parameters: facial expression, body movement, sleep, verbal or vocal ability, consolability, and response to movements and touch Each parameter is scored as 0, 1, 2, or 3. The score is then totaled and the maximum score that can be achieved is 18. The higher the total score, the more intense the pain.

Epidural analgesia

A catheter is inserted in the epidural space usually between the lumbar (L3) and the thoracic (T3) area. The drug, usually fentanyl or morphine, diffuses into the cerebrospinal fluid and crosses the dura mater to the spinal cord. Then it binds with the opioid receptors located at the dorsal horn. The drugs can be administered as bolus injections (a one-time bolus or on an intermittent schedule), a continuous infusion, or PCA. Usually an opioid, such as morphine, fentanyl, or hydromorphone, is given in conjunction with a long-acting local anesthetic such as bupivacaine. Epidural analgesia is typically used postoperatively, providing analgesia to the lower body for approximately 12 to 14 hours. The small amount of medication used with this type of analgesia causes less sedation, thereby allowing the child to participate more actively in postoperative care activities. This type of analgesia also is effective for children undergoing upper or lower abdominal surgeries because it controls localized intense pain, somatic pain, and visceral pain. When epidural analgesia is being administered, additional narcotic analgesics are not given in order to prevent complications such as respiratory depression, pruritus, nausea, vomiting, and urinary retention. Constant assessment is essential because insertion of an epidural catheter and epidural analgesia can lead to infection at the site of the insertion, epidural hematoma, arachnoiditis, neuritis, spinal headache (rare) due to a cerebrospinal fluid leak and respiratory depression. Frequent assessment, typically every 1 to 2 hours, of heart rate, respiratory rate, and depth of sedation, and every 2 to 4 hours of blood pressure, pain level, and motor function, is imperative Assessing for adverse reactions such as nausea and vomiting and pruritus, checking the tubing and catheter site, and ensuring the occlusive dressing is intact are all important nursing interventions. The dermatome, which is the area of the body associated with supply by a particular nerve, that innervates the diaphragm can become suppressed during continuous epidural analgesia, resulting in respiratory depression. It is important to assess the child's sensory level frequently. Using cool water or an alcohol pad, bilaterally touch the child's body every 2 to 3 cm. The level where the child states he or she feels the temperature change is the level of anesthesia.

Patient-controlled analgesia (PCA)

A computerized pump is programmed to deliver an infusion of analgesics via a catheter inserted intravenously, epidurally, or subcutaneously. The analgesic may be given as a continuous infusion, as a continuous infusion supplemented by patient-delivered bolus doses, or as patient-delivered bolus doses only. Typically the child presses a button to administer a bolus dose. The pump has a lockout function that is preset with the dose and time interval

Adolescent pediatric pain tool

A multidimensional self-report type of tool useful for older children, usually between 8 and 17 years of age The tool involves three aspects of assessment. In the first assessment the child identifies the location of the pain on two illustrations of the body—front and back views The child is instructed to color the areas where he or she is hurting. The child is also instructed to color the area as big or as small as how much he or she is hurting. The second portion of the tool involves a scale that ranges from "no pain" to "worst possible pain." The nurse instructs the child to identify the severity of his or her pain. The third assessment is a list of words that may be used to describe pain, such as throbbing, pounding, stabbing, or sharp. The nurse asks the child to point to or circle the words that describe the current pain. Children with limited reading skills or vocabulary may have difficulty with some of the words listed to describe pain. Work with the child and encourage the parents to help the child understand the various descriptive words. Parental participation fosters control over the situation and gives the parents some insight into what their child is experiencing

Pain in adolescents

Adolescents may be concerned primarily about body image and fear losing control over their behavior. This may result in denial or refusal of medications. Their mood and what they think is expected of them will also affect their response to pain. Adolescents often ask numerous questions and pay close attention to how others respond to them. Fearing that their behavior may be viewed as juvenile, they may attempt to remain stoic and not exhibit any emotion. Subtle changes such as increased muscle tension with clenched fists and teeth, rapid breathing, and guarding the affected body part may occur. They may also show lack of interest in everyday activities or a decreased ability to concentrate.

Situational factors of pain

Child's lack of understanding of the source of pain Child's lack of ability to use coping mechanisms or pain-relieving strategies to decrease pain Stress and anxiety in anticipation of pain Child's lack of control of cause of pain Child's lack of ability to understand what to expect from potentially painful experiences Increased anxiety exhibited by the family Overly protective behaviors exhibited by the family Presence of emotions such as fear, anxiety, frustration, distress, underlying anxiety, and depression

Heat and cold applications

Cold results in vasoconstriction and alters capillary permeability, leading to a decrease in edema at the site of the injury. Due to vasoconstriction, blood flow is reduced and the release of pain-producing substances such as histamine and serotonin also is decreased. Moreover, transmission of painful stimuli via peripheral nerve fibers is decreased. Heat results in vasodilation and increases blood flow to the area. It also leads to a decrease in nociceptive stimulation and removal of chemical substances that can stimulate nociceptive fibers. The increase in blood flow alters capillary permeability, leading to a reduction in swelling and pressure on nociceptive nerve fibers. Heat may also trigger the release of endogenous opioids, which mediate the pain response.

Distraction

Counting Repeating specific phrases or words, such as "ouch" Listening to music or singing Playing games, including computer and video games Blowing bubbles or blowing pinwheels or party favors Listening to favorite stories Watching cartoons, television shows, or movies Visiting with friends Humor Associated with lower parental perception of pain and distress in younger children and decreased situational anxiety in older children

Relaxation

Holding an infant or young child closely while stroking the child or speaking in a soft soothing manner, or having the child inhale and exhale slowly using rhythmically controlled deep breathing. It also can involve more sophisticated techniques such as progressive relaxation. With this technique the child is asked to focus on one area of the body and let that body part go limp. Then in an organized fashion, usually working from the toes to the head or vice versa, the child is asked to focus on another body part, making it go limp. Eventually the exercises work through all body areas, leading to relaxation of the entire body.

Pain management

Individualize interventions based on the amount of pain experienced and the child's characteristics, such as developmental level, temperament, previous pain experience, and coping strategies. Use nonpharmacologic and pharmacologic approaches to ease or eliminate the pain. Teach the child and family about pain relief interventions and techniques and discuss with the child and family expectations of pain management.

Biofeedback

Involves having the child gain an awareness of his or her body functions and learn ways to modify them voluntarily. The child usually is taught specific skills about how to modify body functions using an apparatus that measures pain-related changes in muscle tone or physiologic data, such as blood pressure or pulse rate. This teaching usually is performed by a specialized healthcare provider and occurs over several sessions, in advance of the pain experience. With practice, the child learns to control the changes without the apparatus. This technique can be used by older children, such as adolescents, who can concentrate for longer periods of time.

Thought stopping

Involves substituting a pleasurable or positive thought for the painful experience. Examples of positive thoughts might be, "It's only for a short time" or "It's important so I get better." The negative component of the pain is not ignored or suppressed; rather, it is transformed into something positive. Thought stopping also can involve the use of short, positive phrases. For example, the child may repeat "quick stick, feel better go home soon" when he or she anticipates pain or experiences pain. Thought stopping is a useful method for reducing anxiety before and during events associated with pain. Children can be taught to use this technique any time they experience anxiety related to a painful experience. Doing so helps to promote the child's sense of control over the situation.

Topical local anesthesia

It achieves anesthesia to a depth of 2 to 4 mm, so it reduces pain of phlebotomy, venous cannulation, and intramuscular injections for up to 24 hours after the injection. However, it requires a 60- to 90-minute application time to intact skin using an occlusive dressing for superficial procedures and up to 2 to 3 hours for deeper, more invasive procedures EMLA is approved for use in infants 37 weeks' gestation or older Maximum dosage and maximum area of application are based on the child's weight. Lidocaine anesthesia to the area is reached in 15 to 30 minutes and lasts about 60 minutes

Moderate sedation

It is a medically controlled state of depressed consciousness that allows protective reflexes to be maintained so the child has the ability to maintain a patent airway and respond to physical or verbal stimulation The depressed state is obtained by using various agents such as morphine, fentanyl, midazolam, ketamine, chloral hydrate, diazepam, pentobarbital, nitrous oxide, or propofol. The medication used will depend on the expected degree of pain and discomfort, amount of motion restriction needed and individual factors such as age, ability to cooperate, and medical history. Moderate sedation is used for procedures that are painful and stressful. Evidence that the child is experiencing a heightened stress reaction (e.g., attempting to flee, crying inconsolably, or flailing) Verbalization by the child that he or she is frightened and does not want to be touched Inability to remain immobilized, such as during laceration repair or computed tomography Any procedure that is painful and fear provoking

Rectal method

May be used when the child cannot take the medication orally, such as when he or she has difficulty swallowing or is experiencing nausea and vomiting. It is a viable alternative for drug administration. Some analgesics are available in suppository form The absorption rate varies with rectal administration, and children may find insertion of a suppository uncomfortable and embarrassing

Pain perception

Once in the dorsal horn of the spinal cord, the nerve fibers divide and then cross to the opposite side and rise upward to the thalamus. The thalamus responds quickly and sends a message to the somatosensory cortex of the brain, where the impulse is interpreted as the physical sensation of pain. The impulses carried by the fast A-delta fibers lead to the perception of sharp, stabbing localized pain that also commonly involves a reflex response to withdraw from the stimulus. The impulses carried by the slow C fibers lead to the perception of diffuse, dull, burning, or aching pain. The point at which the person first feels the lowest intensity of the painful stimulus is termed the pain threshold

Neuropathic pain

Pain due to malfunctioning of the peripheral or central nervous system. It may be continuous or intermittent and is commonly described as burning, tingling, shooting, squeezing, or spasm-like pain. Examples of neuropathic pain include posttraumatic and postsurgical peripheral nerve injuries, pain after spinal cord injury, metabolic neuropathies, phantom limb pain after amputation, and poststroke pain.

Nociceptive pain

Pain due to noxious stimuli that damages normal tissues or has the potential to do so if the pain is prolonged. The pain perceived often correlates closely with the degree or intensity of the stimulus and the extent of real or possible tissue damage. Nociceptive pain ranges from sharp or burning, to dull, aching, or cramping, and to deep aching or sharp stabbing. Examples of conditions that result in nociceptive pain include chemical burns, sunburn, cuts, appendicitis, and bladder distention.

Chronic pain

Pain that continues past the expected point of healing for injured tissue. It provides no protective function. It may be continuous or intermittent, with and without periods of exacerbation or remission. It often interferes with sleep and performance of activities of daily living. It can result in loss of appetite and depression. Thus, chronic pain impairs a person's ability to function. In contrast to acute pain, environmental and psychological factors influence behaviors associated with chronic pain. In children, chronic, recurrent pain is most commonly associated with abdominal pain, nonspecific headache, limb pain, or chest pain.

Somatic pain

Pain that develops in the tissues. It can be further divided into two groups—superficial and deep. Superficial somatic pain, often called cutaneous pain, involves stimulation of nociceptors in the skin, subcutaneous tissue, or mucous membranes. Typically the pain is well localized and described as a sharp, pricking, or burning sensation. Superficial somatic pain may be due to external mechanical, chemical, or thermal injury or skin disorders. Tenderness commonly is present. Deep somatic pain typically involves the muscles, tendons, joints, fasciae, and bones. It can be localized or diffuse and is usually described as dull, aching, or cramping. Deep somatic pain may be due to strain from overuse or direct injury, ischemia, and inflammation. Tenderness and reflex spasm may be present. In addition, the person may exhibit sympathetic nervous system activation such as tachycardia, hypertension, tachypnea, diaphoresis, pallor, and pupillary dilation.

Visceral pain

Pain that develops within organs such as the heart, lungs, gastrointestinal tract, pancreas, liver, gallbladder, kidneys, or bladder. It is often produced by disease. It usually is diffuse and poorly localized and is described as a deep ache or sharp stabbing sensation that may be referred to other areas. Visceral pain may be due to distention of the organ, organ muscular spasm, contraction, pulling, ischemia, or inflammation. Tenderness, nausea, vomiting, and diaphoresis may be present.

Acute pain

Pain that is associated with a rapid onset of varying intensity. It usually indicates tissue damage and resolves with healing of the injury. Acute pain reflects stimulation of nociceptors and serves a protective function (i.e., alerting the person to a problem).

Preschoolers

Preschoolers may become quiet or try to withdraw and hide in response to actual or perceived pain. Because of their magical type of thinking, preschoolers may believe pain is a punishment for misbehaving or having bad thoughts. Preschoolers may not verbally report their pain, thinking that pain is something to be expected or that the adults are aware of their pain. They can tell someone where it hurts and can use various tools to describe the severity of pain. However, because they may have limited experience with pain, they may have difficulty distinguishing between types of pain (sharp or dull), describing the intensity of the pain, and determining whether the pain is worse or better.

Oral method

Provides relatively steady blood levels of the drug when administered as a scheduled dose. Effectiveness typically occurs 1 to 2 hours after administration. As soon as possible, switch the child to oral dosing from parenteral dosing. However, keep in mind that higher doses of the oral medication may be needed to achieve the same effect.

Pain Assessment

Question the child. Use a reliable and valid pain scale. Evaluate the child's behavior and physiologic changes to establish a baseline and determine the effectiveness of the intervention. The child's behavior and motor activity may include irritability and protection as well as withdrawal of the affected painful area. Secure the parent's involvement. Take the cause of pain into account when intervening. Take action.

Managing chronic pain

Questions should focus on the onset of the pain; its intensity, duration, and location; and any factors that alleviate or exacerbate it. In addition, it is important to question the child and parents about the impact of the pain on the child's daily life, such as sleep, play, eating, school, and interactions with peers, other family members, and friends. Also address the impact of the child's chronic pain on the family's life. Another key area of assessment is determining how the pain affects the child's and family's level of stress. Areas to address include the child's and parents' feelings of hopelessness, anxiety, and depression. Also question the child and parents about what they think has caused the pain and how they have coped with it. In addition, ascertain what methods the child and parents have used to alleviate the pain and the success of these methods. Inquire about any home remedies or alternative therapies that may have been used. Observe the child's overall appearance, gait, and posture. Assess the child's cognitive level and emotional response, especially related to the experience of pain. Expect to complete a neurologic examination and observe for muscle spasms, trigger points, and increased sensitivity to light touch. Abnormal body postures assumed by the child due to chronic pain may result in the development of secondary pain in the muscles and fascia. When children tense their muscles due to fear of examination, somatic pain may occur. Often multiple strategies are combined to address pain relief as well as the pain's impact on other areas, such as sleep or school functioning. When pharmacologic agents are used, the oral form is the method of choice. As with any pain management strategy, education of the child and family is paramount. A referral to a pediatric pain specialist may be needed if the child's pain is not controlled effectively.

Pain in school-age children

School-age children can usually communicate the type, location, and severity of pain. Children older than the age of 8 years can use specific words, such as "sharp as a knife," "burning," or "pulling" to describe their pain. However, they may deny pain in an attempt to appear brave or to avoid further pain related to a procedure or intervention. They may be more concerned with their fear about the illness and its effects rather than the pain. They also may fear being embarrassed by acting-out behaviors in response to pain, such as screaming or thrashing. Thus, a typical response might be to withdraw by staring at the television. Other behaviors that may indicate pain in a school-age child include muscular rigidity, such as clenching the fists, stiffening the body, closing the eyes, wrinkling the forehead, or gritting the teeth.

Transduction

The process of nociceptor activation Mechanical stimuli may include intense pressure to an area, a strong muscular contraction, or extensive pressure due to muscular overstretching. Chemical stimulation may involve the release of mediators, such as histamine, prostaglandins, leukotrienes, or bradykinin, as a response to tissue trauma, ischemia, or inflammation. Thermal stimuli typically involve extremes of heat and cold

Massage and pressure

These methods are helpful in relaxing muscles and reducing tension. In addition, these techniques can aid in distracting the child. Massage can be as simple as rubbing a body part or pressing on an area such as an injection site for about 10 seconds. It can also be more involved, requiring the use of another person to perform the massage. Lotion or ointment can be used during the massage and may provide a comforting effect. Contralateral pressure or massage of the opposite area may be used, especially if the area of pain cannot be accessed or if the affected area is too painful to touch. A more formal method of pressure application is acupressure. In acupressure the fingertip, the thumb, or a blunt instrument is used to apply gentle, firm pressure to specifically designated sites to control pain. The pressure may be applied in one motion followed by releasing, in a circular motion for several minutes and then releasing or with a vibrating motion using the fingertips. The motion of applying and then releasing pressure is thought to facilitate the release of endogenous endorphins and enkephalins

Pain modulators

These substances have been found to change a person's perception of pain. Examples of these neuromodulators include serotonin, endorphins, enkephalins, and dynorphins.

Pain in toddlers

Toddlers can react to painless procedures as intensely as painful ones, with intense emotional upset and physical resistance or aggression. They may bite, hit, scream, or kick. Other behaviors may include being very quiet, pointing to where it hurts, or saying such words as "owww." Facial grimacing and teeth clenching may be noted. They may also react with fear and try to hide or leave the room. They often have limited vocabularies, so it may be difficult for them to express pain. It is important to ask about and encourage the child to verbalize his or her pain. Ensure the use of words the toddler understands, such as "owie" or "boo-boo." Toddlers may demonstrate regressive behaviors, such as clinging to the parent or crying loudly.

Opioid analgesics

Typically used for moderate to severe pain. They are classified as either agonists (when they act as the neurotransmitter at the receptor site) or antagonists (when they block the action at the receptor site). Opioid agents that act as agonists include morphine, fentanyl, meperidine, hydromorphone, oxycodone, and hydrocodone. Opioids that act as mixed agonists-antagonists include pentazocine, butorphanol, and nalbuphine Opioids can be administered orally, rectally, intramuscularly, or intravenously. In addition, some agents such as fentanyl can be administered transdermally or transmucosally. Morphine is considered the "gold standard" for all opioid agonists; it is the drug to which all other opioids are compared and is the drug of choice for severe pain Tramadol is an opioid that has been considered for use in treating moderate pain and is associated with a lower risk of respiratory depression and constipation Opioid agonists, such as morphine, are associated with numerous adverse effects, resulting primarily from their depressant action on the central nervous system.

Atraumatic care

Use topical EMLA, iontophoretic lidocaine, vapocoolant spray, or buffered lidocaine at the intended site of a skin or vessel puncture. Incorporate the use of nonpharmacologic strategies for pain relief in conjunction with pharmacologic methods. Prepare the child and parents ahead of time about the procedure and then keep all equipment out of sight until it is ready to be used. Use therapeutic hugging to secure the child. Use the smallest-gauge needle possible or an automated lancet device to puncture the skin. Use an intermittent infusion device or peripherally inserted central catheter (PICC) if multiple or repeated blood samples are necessary. Coordinate care so that several tests can be performed from one sample if possible. Opt for venipuncture in newborns instead of heel sticks if the amount of blood needed would require much squeezing. Use kangaroo care (skin-to-skin contact) for newborns before and after heel stick. Provide nonnutritive sucking, with sucrose solution, if appropriate; pacifier; or breastfeeding for newborns several minutes before the procedure.

Pain transmission

When nociceptors are activated by noxious stimuli, the stimuli are converted to electrical impulses that are relayed along the peripheral nerves to the spinal cord and brain Neurotransmitters are released to facilitate the transmission process to the brain.

Pain Observation Scale for Young Children (POCIS)

a behavioral assessment tool designed for use in children between 1 and 4 years of age This tool measures seven parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and state of arousal Each parameter is scored as 0 or 1; the maximum score achievable is 7. The higher the score, the greater the pain being experienced by the child.

Neonatal Infant Pain Scale (NIPS)

a behavioral assessment tool that is useful for measuring pain in preterm and full-term neonates Six parameters are measured: facial expression, cry, breathing patterns, arms, legs, and state of arousal Each parameter except for cry is scored as 0 or 1; cry is scored as 0, 1, or 2. The scores are then totaled and the maximum score that can be achieved is 7. A higher score indicates increased pain. This scale does not include any physiologic parameters; therefore, it may not detect early pain in neonates who are too ill to respond, who are receiving paralyzing agents, or who are premature

FACES pain rating scale

a self-report tool that can be used by children as young as 3 or 4 years of age The scale consists of six illustrations of faces arranged horizontally with expressions ranging from smiling (indicating no hurt) to crying with frowning (indicating hurts worst). Under each face is a short description such as "hurts little bit" and a number. The number scale can be 0, 1, 2, 3, 4, and 5 or 0, 2, 4, 6, 8, and 10. The nurse explains the words associated with each face to the child. Then the nurse asks the child to select the facial expression that best describes the level of pain he or she is feeling. The nurse then documents the number corresponding to the word description and face.

Poker chip tool

a self-reporting pain assessment tool that uses four red poker chips to quantify the child's level of pain The chips are arranged in a horizontal line on a surface in front of the child. Starting with the chip closest to the child's left side, the nurse points to the chip and explains that the first chip means a little hurt, the next chip means more hurt, the third chip means more hurt, and the fourth chip means the worst hurt ever. Then the nurse asks the child how many "pieces of hurt" he or she is having If the child is not experiencing any pain, typically the child will state that he or she isn't having any. When the child identifies the number of "pieces of hurt," the nurse follows up by asking the child to tell the nurse more about his or her hurt The poker chip tool is useful for assessing pain in children 4 to 7 years of age

Pain

an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in terms of such damage

Local anesthetics

commonly used to provide analgesia for procedures. They are effective in providing successful pain relief with only minimal risk of systemic adverse effects.

Adjuvant drugs

drugs that are used to promote more effective pain relief, either alone or in combination with nonopioids or opioids. Their primary indication is for diagnoses other than pain.

Biophysical interventions

focus on interfering with the transmission of pain impulses reaching the brain. The interventions involve some type of cutaneous stimulation near the site of the pain. This stimulation decreases the ability of the A-delta and C fibers to transmit pain impulses. Examples of biophysical interventions include the use of sucking and sucrose, application of heat and cold, massage and pressure, and transcutaneous electrical nerve stimulation (TENS).

Nonopioid analgesics

include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, ketorolac, naproxen, indomethacin, diclofenac, and piroxicam These agents may be used to treat mild to moderate pain, often for conditions such as arthritis; joint, bone, and muscle pain; headache; dental pain; and menstrual pain. Acetaminophen, probably the most widely known nonopioid analgesic, and ibuprofen are also commonly used to treat fever in children. typically administered orally or rectally. In some cases, such as with postoperative pain, they may be administered intravenously as a continuous infusion or as bolus doses. Acetaminophen is a relatively safe medication and it does not have the same GI or antiplatelet effects of NSAIDs therefore it is useful in children with cancer, with bleeding or clotting disorders or children on anticoagulants. Acetaminophen toxicity and resulting hepatotoxicity can occur with misuse and overdosing. Adverse effects associated with NSAIDs are uncommon but include gastrointestinal irritation, blood clotting problems, and renal dysfunction. Nonopioids are relatively safe, have few incompatibilities with other medications, and do not depress the central nervous system. Unfortunately, they exhibit a ceiling effect for analgesia. That is, after a certain level, they do not provide increasing pain relief even when administered at increased doses. As a result, they may be combined with opioids for more effective pain relief.

Sucking and Sucrose

infants show reduced pain behaviors after ingestion of sucrose or other sweet-tasting solutions such as glucose during single-event procedures, such as heel lancing

Pain in infants

infants, including preterm infants, experience pain and can distinguish pain from other tactile experiences Research suggests that neonates, especially preterm infants, actually experience pain at a greater intensity than older-age children and adults In preterm and term newborns, behavioral and physiologic indicators are used for determining pain. Behavioral indicators include facial expression, such as brow contracting and chin quivering; body movements; and crying Physiologic signs include changes in heart rate, respiratory rate, blood pressure, oxygen saturation levels, intracranial pressure, vagal tone, palmar sweating, and an increase in plasma cortisol or catecholamine levels The older infant may display an angry facial expression, but the eyes are open. He or she often demonstrates a definite withdrawal response when the area is stimulated. The older infant cries loudly and tries to push away the stimulus that is causing the pain. Other manifestations include irritability, restless sleeping, and poor feeding. Infants also demonstrate physiologic responses to pain. These may include: Increased heart rate, usually averaging approximately 10 beats per minute; possibly bradycardia in preterm newborns Decreased vagal tone Decreased oxygen saturation Palmar or plantar sweating (as measured by skin conductivity testing); not reliable in infants before 37 weeks' gestation

Visual analog and numeric scales

involve a horizontal or vertical line with marked endpoints. With a visual analog scale, the endpoints are identified as no pain and worst pain. A numeric scale typically has endpoints of 0 and 10, reflecting no pain and worst pain, respectively With the visual analog scale, the child makes a line that best describes the level of pain. The nurse then measures the distance from the "no pain" endpoint to the child's mark and records this as the pain score. With the numeric scale, the nurse asks the child to pick the number that best describes his or her level of pain. The visual analog scale can be used in children 8 years or older but some studies report effectiveness in children 5 to 7 years of age The numeric scale can be used with children 8 years or older

Behavioral-Cognitive strategies

involve measures that require the child to focus on a specific area rather than the pain. These strategies help to change the interpretation of the painful stimuli, reducing pain perception or making pain more tolerable. These strategies help to decrease negative attitudes, thoughts, and anxieties, thereby improving the child's coping mechanisms Common behavioral-cognitive strategies include relaxation, distraction, imagery, biofeedback, thought stopping, and positive self-talk.

Imagery

involves the use of the imagination to create a mental image. This mental image usually is a positive, pleasurable image, but it need not be real. The child is encouraged to include details and sensations that are associated with the image, such as specific descriptions of the image, colors, sounds, feelings, and smells. In some instances, the child may write down or record the image. When pain occurs, the child is encouraged to create the mental image or read or listen to the description.

Physical examination of pain

primarily involves the skills of observation and inspection. These skills are used to assess for physiologic and behavioral changes that indicate pain. Auscultation also may be used to assess for changes in vital signs, specifically heart rate and blood pressure. Look for facial expressions of discomfort, grimacing, or crying. Be alert for movements that may suggest pain. Inspect the skin for flushing or diaphoresis, possible indicators of pain. Also monitor vital signs for changes. Pulse or heart rate, respiratory rate, and blood pressure may increase. Other physiologic parameters that suggest pain may include elevated intracranial pressure and pulmonary vascular resistance and decreased oxygen saturation levels. Be alert for irritability and restlessness. Watch for clenching of teeth or fists, body stiffening, or increased muscle tension. Note any changes in the child's behavior.

Oucher pain rating scale

six photographs are used: "no hurt" is placed at the bottom of the arrangement and "most hurt" at the top. Alongside the photos is a scale ranging from 0 to 10 that corresponds to the facial expressions in the photographs After explaining the photos and numeric scale, the child is asked to point to the number that best describes his or her level of pain This scale is useful for self-reporting of pain in children between 3 and 12 years of age

Nociceptors

specialized receptors which become activated when they are exposed to noxious stimuli.

Positive self-talk

the child is taught to say positive statements when he or she is experiencing pain. For example, the child may be taught to say, "I will feel better and be able to go home and play with my friends."

Intravenous method

the method of choice in emergency situations and when pain is severe and quick relief is needed. With intravenous administration, the drug usually takes effect within 5 minutes. Intravenous administration can be accomplished with bolus injections or continuous infusions. Continuous infusions may be preferred over bolus doses because steady blood levels are more easily maintained, thereby enhancing the drug's effect in relieving pain. Typically, opioids such as morphine, hydromorphone, and fentanyl are used due to their short half-life and decreased risk for toxicity.