Chapter 39 Pain

Topical Heating and Cooling

Application of cold or heat to a painful area provides pain relief and comfort; the mechanism of action is uncertain (McCaffery & Pasero, 1999). Effectively treats pain from disease states, injuries, and procedures (Twycross & Dowden, 2009). Used by nurses, physical therapists, sports trainers, and other clinicians.

Acupuncture

Based on traditional Chinese concepts of energy balance; insertion of very thin needles through the skin to stimulate anatomic points (meridians). Limited research in children (Twycross & Dowden, 2009). Effective for acute and chronic pain in children (Kundu & Berman, 2007). Treatment is done by a trained acupuncturist; children may have concerns about the use of needles.

CRIES pain scale

Five behavioral categories: C rying, R equires O2 for Sao2 <95%, I ncreased vital signs, E xpression, S leepless; 02 for each with total score from 0-10. A higher score indicates greater pain or distress (Krechel & Bildner, 1995). Neonates; 0-6 mo

FLACC

Five behavioral categories: F ace, L egs, A ctivity, C ry, C onsolability. Each scored from 0-2, resulting in a total score from 0-10. A higher score indicates higher pain or distress (Merkel, Voepel-Lewis, & Malviya, 2002). Infants and preverbal or nonverbal children

Poker Chip Tool

Four poker chips are used, with each chip representing a piece of hurt. One poker chip represents a little hurt, and four chips represent the most hurt the child could have (Hester, Foster, Jordan-Marsh, et al., 1998). 4-12 yr

Biofeedback

Involves measurement of physiologic indicators (e.g., blood pressure, heart rate, skin temperature, sweating, and muscle tension) using specialized equipment. Alerts patients instantly to early signs of tension so they can commence relaxation techniques; the child learns to control physiologic responses based on the biofeedback. Has proven effective for treatment of headaches and other types of pain (Twycross & Dowden, 2009). Requires trained personnel to administer and teach tension recognition and relaxation techniques.

Myth: Narcotic administration can easily cause respiratory depression.

No data support the belief that children are at higher risk for respiratory depression than adults. Respiratory depression is rare

Numeric Rating Scale

Patient is asked to give a number that reflects the pain level: 0 = no pain; 13 = mild; 46 = moderate; 710 = severe (Pasero & McCaffery, 2011). Child 9 yr and older

Hypnosis

Progressive, systematic, purposeful relaxation of one muscle group at a time through contraction and then relaxation of muscles; usually proceeds from head to toe. Often used effectively for migraine and tension headaches (Twycross & Dowden, 2009). Teach the older child and adolescent the technique; encourage frequent practice.

Regulated (controlled) breathing

Provides a focal point for distraction and produces relaxation. A simple mode for biofeedback. Teach the child how to achieve a slow, rhythmic breathing pattern; teach parents the technique and how to help their child.

Massage

Purposeful manipulation of the body, providing tactile and kinesthetic stimulation. Evidence regarding benefits is varied; strongest effect is anxiety reduction (Beider, Mahrer, & Gold, 2007). Performed by massage therapists; nurses may provide basic massage.

TENS

Purposeful manipulation of the body, providing tactile and kinesthetic stimulation. Evidence regarding benefits is varied; strongest effect is anxiety reduction (Beider, Mahrer, & Gold, 2007). Performed by massage therapists; nurses may provide basic massage.

Distraction

Related to the gate control theory, use of distraction techniques "closes the gate" by focusing the child on the distraction rather than on the pain experience. Active methods are more effective than passive (Twycross & Dowden, 2009). Wide range of techniques (e.g., playing with toys, video games, blowing bubbles, watching videos, listening to music, singing, reading). Relatively easy to use and often employed by nurses and other health care providers to help children cope with pain. Distraction must be developmentally appropriate for the child.

Myth: There is a correct or standard amount of pain associated with a specific injury or procedure.

The amount of pain a child experiences varies and cannot be predicted because of individual cognitive, developmental, and emotional factors affecting the child

Guided Imagery

The child is encouraged to remember or imagine the sounds, sights, and smells of an enjoyable item or experience such as playing in the water or a birthday celebration (Srouji, Ratnapalan, & Schneeweiss, 2010). The facilitator talks in a soft, calm voice while "guiding" the child's imagination. Can be coupled with relaxation techniques such as rhythmic breathing. Facilitated by trained health care providers (e.g., nurse, child-life therapist). Studies have shown reductions in children's pain from a variety of causes

Adolescent and Pediatric Pain Tool (APPT)

Three-part tool composed of a body outline, an intensity scale, and a pain descriptor word list (Savedra, Tesler, Holzemer, et al., 1992). 8-17 yr

Visual Analog Scale (VAS)

Usually a 10-cm line with one end representing "no pain" and the opposite end "the worst pain" (Cline, Herman, Shaw, et al., 1992). 7-18 yr

Myth: Children can easily become addicted to narcotic analgesics.

Reality: There is no identified characteristic of childhood physiology or development that indicates any increased risk of physiologic or psychological dependence. The actual risk of addiction is very low

BOX 39-3 PAIN EXPERIENCE HISTORY

Child Form∗ • What word(s) do you use to describe your pain? • Tell me what pain is. • What does a child with pain look like? • How do you feel when you have pain? • Have you ever had pain just like this before? Tell me about a time when you had pain. • Is the pain you have now different than pain you have had before? • Do you tell others when you hurt? Who do you tell? • What helps the most to take your hurt away? • What do you do for yourself when you are hurting? • What do you want other people to do for you when you hurt? • What don't you want other people to do for you when you hurt? • Did anyone tell you that you might have pain? If yes, who told you and how did they tell you? • Is there anything else at all you want to tell me about pain? (If yes, have child describe.) Parent Form • What word or words does your child use to describe pain? • Describe the pain experiences your child has had in the past. • Does your child tell you or others when in pain? • How do you know when your child is in pain? • How does your child usually react to pain? • What do you do when your child is in pain? • What does your child do when he or she is in pain? • What works best to take away your child's pain? • Is there anything special that you would like me to know about your child and pain? (If yes, describe.)

DRUG GUIDE: Acetaminophen

Classification: Analgesic, antipyretic. Action: Unknown, thought to produce analgesia by blocking generation of pain impulses. Indications: Mild pain or fever. Dosages and Routes: By mouth or rectal suppository dosage 10-15 mg/kg/dose every 4-6 hr (every 6-8 hr for neonates). Maximum dose of 90 mg/kg/24 hr; not to exceed 4000 mg/day. Absorption: Rapid and almost complete absorption from gastrointestinal (GI) tract; less complete absorption from rectal suppository; peak effects in 1-1.5 hr. Excretion: 90%-100% of drug excreted as metabolites in urine; excreted in breast milk; effects last 4-6 hr. Contraindications: Hypersensitivity to acetaminophen or phenacetin; administration to patients with anemia or hepatic disease; cautious use in arthritic or rheumatoid conditions affecting children younger than 12 yr; thrombocytopenia. Adverse Reaction: Negligible with recommended dosage; rash. Nursing Considerations: May be crushed. Chewable tablets need to be thoroughly chewed and wet before swallowing. With high doses or long-term therapy, periodic tests of hepatic, renal, and hematopoietic function are advised. Caution the parents about giving other medications that also contain acetaminophen. No more than six doses in 24 hr should be given to children unless prescribed by a physician. Available in infant strength (drops). Be sure to advise parents to check the strength before administering acetaminophen (Tylenol) in liquid, chewable tablet, or tablet forms, to prevent overdosing.

DRUG GUIDE: Ibuprofen

Classification: Nonsteroidal antiinflammatory drug (NSAID), analgesic. Action: Blocks prostaglandin synthesis. Indications: Relief of mild to moderate pain. Chronic, symptomatic rheumatoid arthritis and osteoarthritis. Dosages and Route: By mouth dosage 5-10 mg/kg/dose every 6-8 hr. Not to exceed 40 mg/kg/24 hr. Juvenile arthritis dosage 30-50 mg/kg/24 hr. Medication comes in liquid form for young children. Absorption: 80% absorbed from gastrointestinal (GI) tract; peak action in 1-2 hr. Excretion: Excreted primarily in urine; some biliary excretion. Contraindications: Contraindicated in children in whom urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps are precipitated by other NSAIDs; active peptic ulcer; bleeding abnormalities. Precautions: Hypertension, history of GI ulceration, impaired hepatic or renal function, chronic renal failure. Adverse Reactions: Heartburn, nausea, vomiting, epigastric or abdominal discomfort or pain, GI ulceration. Nursing Considerations: Give with meals or milk to decrease GI intolerance. If the child is unable to swallow a tablet, administer the medication in liquid form. Ibuprofen that is not enteric-coated can be crushed and mixed with a small amount of food or liquid before swallowing.

DRUG GUIDE: Ketorolac

Classification: Nonsteroidal antiinflammatory drug (NSAID), analgesic. Action: Blocks prostaglandin synthesis. Indications: Short-term management of moderate acute pain. Dosages and Route: Children older than 6 months, IV dosage 0.5-1 mg/kg one time, up to 30 mg followed by 0.5 mg/kg/dose every 6 hr, up to a maximum of 60 mg/24 hr. Absorption: Peak action in 15 min. Excretion: Excreted in the urine; effects last 4-6 hr. Contraindications: Contraindicated in patients in whom urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps are precipitated by other NSAIDs; active peptic ulcer; bleeding abnormalities, severe renal impairment. Precautions: Cautious use with history of ulcers, impaired hepatic or renal function. Adverse Reactions: Drowsiness, dizziness, nausea, gastrointestinal (GI) pain, hemorrhage. Nursing Considerations: Do not administer longer than 5 days. Monitor renal and liver function studies, signs and symptoms of GI upset or bleeding.

DRUG GUIDE: Hydrocodone

Classification: Opioid analgesic. Action: Binds to opiate receptors in the central nervous system (CNS) to diminish pain. Indications: Mild pain to moderate pain; acute pain Dosage and Routes: By mouth dosage 0.1 to 0.2 mg/kg every 3-4 hr. Maximum dosage dependent on acetaminophen or ibuprofen content of product. Absorption: Onset 10-20 min; duration 4-6 hr. Excretion: Excreted in the urine, half-life 3.5-4.5 hr. Contraindications: Hypersensitivity to codeine, hydromorphone, or other morphine derivatives, addiction. Precautions: Addictive personality, increased intracranial pressure, respiratory depression, hepatic disease, renal disease. Cautious use in head injuries, increased intracranial pressure, asthma, and other respiratory conditions. Adverse Reactions: Nausea, vomiting, constipation, pruritus, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, dependence. Nursing Considerations: Nausea is a common side effect; report if this is accompanied by vomiting. Because dizziness and lightheadedness may occur, supervision of ambulation and other safety precautions may be necessary. Assess respiratory status carefully; assess for CNS changes and implement appropriate safety measures.

DRUG GUIDE: Morphine

Classification: Opioid analgesic. Action: Binds with central nervous system (CNS) opiate receptors; alters physical and emotional response to pain. Indications: Moderate to severe pain. Acute and chronic pain. Dosages and Routes: By mouth or per rectum intermittent dosage 0.2-0.5 mg/kg/dose every 4-6 hr; extended-release dosage 0.3-0.6 mg/kg/dose every 8-12 hr. Intravenous (IV) or subcutaneous intermittent dosage 0.05-0.1 mg/kg/dose every 2-4 hr, maximum dose 15 mg/dose. Continuous IV infusion dosage 0.01-0.05 mg/kg/hr. Absorption: Variable absorption from the gastrointestinal (GI) tract; peak action 60 min orally, 10-20 min IV. Excretion: Excreted primarily in the urine; 7% to 10% excreted in bile. Effects last up to 7 hr. Contraindications: Hypersensitivity to opioids, increased intracranial pressure, seizure disorders, chronic pulmonary disease, respiratory depression. Precautions: Cautious use with cardiac arrhythmias, reduced blood volume, addictive personality. Adverse Reactions: Primarily CNS symptoms: dizziness, lightheadedness, drowsiness, sedation, lethargy, euphoria, agitation, restlessness, respiratory depression. GI symptoms; nausea, vomiting, constipation. Genitourinary (GU) symptoms: urinary retention. Pruritus. Nursing Considerations: Nausea is a common side effect; report if this is accompanied by vomiting. Because dizziness and lightheadedness may occur, supervision of ambulation and other safety precautions may be necessary. Assess respiratory status carefully and frequently; assess for CNS changes and implement appropriate safety measures. Monitor intake and output related to urinary retention and constipation. Begin with the lowest dosage and titrate dosage up or down to maximize pain relief and minimize adverse effects.

DRUG GUIDE: Codeine

Classification: Opioid analgesic. Action: Binds with opiate receptors in the central nervous system (CNS); alters both perception of and emotional response to pain. Indications: Mild to moderate pain. Dosage and Routes: By mouth dosage 0.5-1 mg/kg/dose every 4-6 hr; maximum dose 60 mg/dose. Absorption: Readily absorbed from gastrointestinal (GI) tract, with peak action in 1-2 hr. Distribution: Crosses placenta; distributed into breast milk. Excretion: Effects last approximately 4 hr; excreted in urine. Contraindications: Hypersensitivity to codeine, hydrocodone, or other morphine derivatives; hepatic or renal dysfunction, addiction. Precaution: Use cautiously in very young children and those with an addictive personality. Adverse Reactions: Primarily CNS symptoms: dizziness, lightheadedness, drowsiness, sedation, lethargy, euphoria, agitation, restlessness, respiratory depression. GI symptoms: nausea, vomiting, constipation. Genitourinary (GU) symptoms: urinary retention. Pruritus. Nursing Considerations: May be given with food or milk to lessen GI upset. Nausea is a common side effect; report if this is accompanied by vomiting. Because dizziness and lightheadedness may occur, supervision of ambulation and other safety precautions may be necessary. Assess respiratory status carefully; assess for CNS changes and implement appropriate safety measures. Available in combination with acetaminophen: Tylenol with codeine No. 2 = 15 mg codeine/300 mg acetaminophen, Tylenol with codeine No. 3 = 30 mg codeine/300 mg acetaminophen, Tylenol with codeine No. 4 = 60 mg codeine/300 mg acetaminophen.

Drug Guide: Methadone

Classification: Opioid analgesic. Action: Depresses pain impulse transmission at the spinal cord level through interaction with opioid receptors, thus producing central nervous system (CNS) depression. Indications: Severe acute and chronic pain, opioid withdrawal. Dosages and Routes: By mouth, subcutaneous, intramuscular (IM) and intravenous (IV) dosage 0.05-0.1 mg/kg/dose every 4-6 or 12 hr. Maximum single dose 10 mg. Absorption: Variable absorption from the gastrointestinal (GI) tract; peak action 60 min orally, 20 min IV. Excretion: Excreted in the urine, crosses the placenta, excreted in breast milk. Half-life is 15-30 hr. Contraindications: Hypersensitivity to this drug, chlorobutanol injection, addiction. Precautions: Cautious use with addictive personalities, increased intracranial pressure, respiratory depression, hepatic or renal disease. Adverse Reactions: Sedation, dizziness, confusion, euphoria, seizures, respiratory depression, hypotension, bradycardia, palpitations, nausea, vomiting, constipation, urinary retention. Nursing Considerations: Carefully and frequently assess level of sedation and respiratory status. Assess cough reflex. Monitor intake and output checking for urinary retention and constipation. Titrate dosage up or down to maximize pain relief and minimize adverse effects.

DRUG GUIDE: Hydromorphone

Classification: Opioid analgesic. Action: Inhibits ascending pain pathways in the central nervous system (CNS), increases pain threshold, alters pain perception. Indications: Moderate to severe pain, acute and chronic pain. Dosages and Routes: By mouth or subcutaneous dosage 0.03-0.08 mg/kg/dose every 4 hr with maximum starting dose of 7.5 mg. Intravenous (IV) intermittent dosage 0.015 mg/kg/dose every 3-6 hr. IV continuous infusion dosage 3-5 mcg/kg/hr. Absorption: Onset 15-20 min; peak 0.5-1 hr; duration 4-5 hr. Excretion: Excreted in the urine, half-life 3.5-4.5 hr. Contraindications: Hypersensitivity, addiction. Precautions: Addictive personality, increased intracranial pressure, respiratory depression, hepatic disease, renal disease. Cautious use in head injuries, increased intracranial pressure, asthma, and other respiratory conditions. Impaired renal or hepatic function. Adverse Reactions: Nausea, vomiting, constipation, pruritus, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, dependence, increased urine output, urinary retention, seizures, palpitations, bradycardia, tachycardia, hypotension, other changes in blood pressure. Nursing Considerations: Nausea is a common side effect; report if this is accompanied by vomiting. Because dizziness and lightheadedness may occur, supervision of ambulation and other safety precautions may be necessary. Assess respiratory status carefully; assess for CNS changes and implement appropriate safety measures. Titrate dosage up or down to maximize pain relief and minimize adverse effects.

DRUG GUIDE: Oxycodone

Classification: Opioid analgesic. Action: Inhibits ascending pain pathways in the central nervous system (CNS), increases pain threshold, alters pain perception. Indications: Moderate to severe pain. Acute or chronic pain. Dosage and Routes: By mouth starting dosage 0.1-0.2 mg/kg/dose every 4-6 hr; maximum starting dose 10 mg. Absorption: Onset 10-20 min; duration 4-6 hr. Excretion: Excreted in the urine, half-life 3.5-4.5 hr. Contraindications: Hypersensitivity to oxycodone, codeine, or other morphine derivatives; hepatic or renal dysfunction, addiction. Precautions: Addictive personality, increased intracranial pressure, respiratory depression, hepatic disease, renal disease. Cautious use in patients with head injuries, increased intracranial pressure, asthma, and other respiratory conditions. Adverse Reactions: Nausea, vomiting, constipation, pruritus, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, dependence. Nursing Considerations: Nausea is a common side effect; report if this is accompanied by vomiting. Because dizziness and lightheadedness may occur, supervision of ambulation and other safety precautions may be necessary. Assess respiratory status carefully; assess for CNS changes and implement appropriate safety measures. Titrate dosage up or down to maximize pain relief and minimize adverse effects.

DRUG GUIDE: Fentanyl

Classification: Opioid analgesic. Action: Opioid agonist with actions similar to morphine and meperidine, but action is faster and less prolonged. Indications: Moderate to severe pain, particularly for brief procedures and when children are critically ill or high risk. Transdermal fentanyl is for moderate to severe chronic pain only; experience with children is limited. Dosages and Routes: Intramuscular (IM) and intravenous (IV) intermittent dosage 1-2 mcg/kg/dose every 30-60 min. IV continuous infusion dosage 0.05-3 mcg/kg/hr. Transdermal patch dosage 25 mcg/hr system; used only in opioid-tolerant children older than 2 years. Absorption: Absorbed rapidly after IV administration; 6-8 hr transdermally. Excretion: Excreted in the urine. Lasts 30-60 min IV; 72 hr transdermally. Contraindication: Hypersensitivity, addiction, patients who have received monoamine oxidase inhibitors within 14 days. Precautions: Addictive personality. Use cautiously in children with head injuries, increased intracranial pressure, respiratory problems, hepatic and renal dysfunction. Adverse Reactions: Nausea, vomiting, constipation, pruritus, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, dependence, increased urine output, urinary retention, seizures, palpitations, bradycardia, tachycardia, hypotension, other changes in blood pressure. Nursing Considerations: Watch carefully for signs and symptoms of respiratory distress and depression. Have oxygen, resuscitative equipment, and naloxone available. Administer slow IV push to prevent chest wall rigidity.

BOX 39-4 ASPECTS OF PATIENT-CONTROLLED ANALGESIA (PCA) ORDERS

Medication/concentration: _______________________________ Mode: PCA only _________ PCA and basal infusion __________ Continuous infusion only ____________________ Dosages: PCA bolus _______________ mg (recommended starting dose is 0.02 mg/kg/dose for morphine) Basal rate or continuous infusion ________________ (recommended starting dose is 0.02 mg/kg/hr for morphine) Lock-out: ____________ minutes (usual is 6-10 min as needed) 1-hour limit: ___________ mg PCA and basal rate combined (usual is 0.075 mg/kg for morphine)

BOX 39-2 INDICATORS OF PAIN ACCORDING TO DEVELOPMENTAL LEVELS

Neonate and Infant • Usually demonstrate changes in facial expression, including frowns, grimaces, wrinkled brow, expression of surprise, and facial flinching • May demonstrate increases in blood pressure and heart rate, and decrease in oxygen saturation • High-pitched, tense, harsh crying • Tend to demonstrate a generalized or total body response to pain that becomes more purposeful as the infant matures • May thrash extremities and exhibit tremors • Older infants may localize the pain, rubbing the painful area, or pull away and guard the involved part Toddler • Likely to demonstrate loud crying • Able to verbalize words that indicate discomfort such as "ouch," "hurt," "boo-boo" • May attempt to delay procedures perceived as painful • May demonstrate generalized restlessness • May guard the site • May touch painful areas • May run from the nurse Preschooler • May think the pain is punishment for something he or she said or did • Likely to cry and struggle • Able to describe the location and intensity of pain (e.g., "ear hurts bad") • May demonstrate regression to earlier behaviors, such as loss of bladder and bowel control • May demonstrate withdrawal • May deny pain to avoid taking oral medicine or a possible injection • May have been told to "be brave" and deny pain, even if pain is present School-Age Child • Able to describe pain and quantify pain intensity • Fears bodily injury • Has an awareness of death • May demonstrate stiff body posture • May demonstrate withdrawal • May procrastinate or bargain to delay procedure Adolescent • Perceives pain at a physical, emotional, and cognitive level • Understands cause and effect • Able to describe pain and quantify pain intensity • May have increased muscle tension • May demonstrate withdrawal and decreased motor activity • May use words such as "sore," "ache," or "pounding" to describe pain

Progressive Muscle Relaxation

Progressive, systematic, purposeful relaxation of one muscle group at a time through contraction and then relaxation of muscles; usually proceeds from head to toe. Often used effectively for migraine and tension headaches (Twycross & Dowden, 2009). Teach the older child and adolescent the technique; encourage frequent practice.

Myth: Neonates do not feel pain because of incomplete myelinization in peripheral nerves and the central nervous system (CNS).

Reality: Myelinization is not necessary for pain perception. Central and peripheral structures required for nociception are present and functional early in gestation. Therefore infants have the neurologic capacity for pain perception at the time of birth, even those born prematurely (Franck, Greenberg, & Stevens, 2000).

Myth: Children have no memory of pain.

Reality: Feeding and sleeping differences have been reported in studies of infants who experienced pain, which suggests that the procedure had consequences extending beyond the event

Techniques for neonates and infants

Several noninvasive techniques used during and/or after a painful procedure or experience include breastfeeding; oral sucrose; nonnutritive sucking on a pacifier; skin-to-skin contact (kangaroo care) with the infant positioned directly on the mother's chest; holding and rocking by a parent or caregiver; and tucking or swaddling where the infant is wrapped with the extremities close to the trunk (Srouji et al., 2010). Nurses may use a variety of techniques separately or in combination to distract the infant and reduce the severity of the pain experience. Parents can be taught to use techniques.

Faces pain scale

Six cartoon faces with neutral to gradually increasing painful expressions, corresponding to an analog scale with words ranging from a happy face (0; No Hurt) to a crying face (5 or 10; Hurts Worst). Accommodates a 0-5 or 0-10 system (Hockenberry & Wilson, 2009).

COMFORT Behavior Scale

Six categories are scored: Alertness, Calmness/Agitation, Respiratory response (if on ventilator) or Crying (if breathing spontaneously), Physical Movement, Muscle Tone, Facial Tension; 1-5 for each category with total score from 6-30. A higher score indicates greater pain or distress (Van Dijk, Peters, Van Deventer, et al., 2005). Infants and children in critical care settings

NURSING QUALITY ALERT: Disadvantages of Intramuscular (IM) Analgesics

• Most children have a significant fear of pain associated with IM injections. • Fluctuations in tissue absorption lead to peaks and troughs in analgesia. • Children may not have enough suitable sites for IM injections. • Some medications can cause injury to tissues and nerves. • IM analgesics have a shorter duration of action than do oral analgesics. • IM analgesics are contraindicated in children with low platelet counts and bleeding disorders such as hemophilia.

PATIENT-CENTERED TEACHING: Pain Management for Children at Home

• Parents are given a pain assessment tool with instructions on accurate use. They should verbalize understanding about the tool and give a return demonstration using the tool with their child. • The dose, route, and schedule for all pain medications are explained to the parents verbally and in writing. All instructions should be in the appropriate language for the family, using clear, straightforward terminology that is at an educational level suitable for the parents. • Non-pharmacologic interventions that are appropriate and comforting for the child's pain (e.g., massage, warm or cold compresses, repositioning) are explained and demonstrated. Written instructions are provided as necessary. • Parents are instructed to notify the primary health care provider if interventions for pain management are ineffective or if the child shows behavior or physiologic changes not consistent with the expected outcomes for the child. • Parents are given a phone number where they can contact a nurse or other health care provider if they have any questions about their child's condition once the child is in the home setting.

NURSING QUALITY ALERT: Pain Management for Children

• The preferred route of administering analgesics to children is oral or intravenous (IV). • As soon as the child can tolerate oral intake, pain medication should be changed from the IV to the oral route. • After starting with the recommended initial dose for opioids, the dose is adjusted (titrated) to achieve best pain management with the fewest side effects. • Opioids do not have a dose limit. The maximum dose is the dose that causes unacceptable side effects. • Infants and children receiving epidural opioids should be monitored by a cardiac and apnea monitor, and pulse oximetry. • A cardiac and apnea monitor and a pulse oximeter may be required to monitor certain infants and children receiving IV opioids (e.g., neonates, children who are opioid naïve, children with a history of apnea or other respiratory difficulties). The risk of respiratory depression is greatest during the first 24 hours of administration. • If respiratory depression occurs with opioid use, naloxone hydrochloride should be administered for reversal, if oxygen and stimulation of the child are ineffective.

NURSING QUALITY ALERT: Assessing Pain in Children

• The use of a pain assessment tool is imperative in the assessment of pain in children and the evaluation of pain management interventions. The tool used is documented in the patient's medical record. • If the child is unable to express or quantify pain, use parents as one of the first resources to assist in assessing the child's pain and response to interventions. • Behavioral changes such as guarding, body positioning, crying, grimacing and other altered facial expressions, and changes in activity level, may or may not be seen in a child experiencing pain. • Physiologic changes are only one source of information when assessing pain in the neonate or infant. Other states, such as fear and anxiety, may also cause physiologic changes. Physiologic changes tend to occur during an acute pain experience and then return to normal; they may not be valid indicators of sustained or chronic pain.