Ch36: Pain Management in Children

The experienced nurse is providing shift handoff to a graduate nurse. Which statement of pain management by the graduate nurse requires clarification by the expert nurse?

"Children should not be given morphine, because they are at risk for respiratory depression." Explanation: All the statements are true except for the one stating that children should not be given morphine because of a danger of respiratory depression. If the dosage of an opiate is based on the child's size, then there is no more danger of respiratory depression in children than in adults. Morphine is the most common pain medication for children with moderate to severe pain.

A parent expresses concern about a 3-year-old child's pain while having blood drawn and asks the nurse what she can do to help the child. Which response by the nurse will be most beneficial?

"Focus on a story during the blood draw."

When providing education to a parent regarding pain management for a toddler with otitis media, which statement by the parent indicates further teaching is needed?

"I should give my toddler one baby aspirin." Explanation: Children, including toddlers, should not use acetylsalicylic acid for routine pain management or to treat fever because of the increased risk of Reye syndrome. The use of the other options is appropriate and all statements indicate an understanding of pain management for this child.

The nurse is caring for a client who is in a sickle cell crisis. The child is hospitalized for pain management during the crisis. The parents tell the nurse that they do not think their child needs any pain medication because the child is sleeping a lot. How should the nurse respond?

"I understand why you think your child is not in pain; sleep is often a way for children to cope with pain." Explanation: Sleep or play may be a coping strategy for the child in pain, and sleep may reflect exhaustion of the child who is coping with pain; therefore, the nurse and parents should not assume the child is pain-free. There is no need to wait for the child to express the pain level to the nurse. Often, children deny pain or may assume that others know how they are feeling and thus will not verbalize their pain. Telling the parents that the medication must be given as prescribed does not address the parents' concern.

The parents of a newborn are deciding if they want their newborn circumcised. The parents ask the nurse if their newborn can feel any pain during the procedure. How should the nurse respond?

"It is hard to know for sure, but research shows that it is possible for newborns to experience pain." Explanation: Research has demonstrated that the nervous system structures needed for pain impulse transmission and perception are present before birth (American Medical Association, 2013). Therefore, children of any age, including preterm newborns, are capable of experiencing pain.

The parent of a child with periorbital cellulitis comes to the nurses' station and asks to speak with the nurse. The parent states, "The oral pain medication you gave my child 45 minutes ago is not working!" What is the nurse's best response?

"Oral medications take about 45 minutes to start working. I will be back in 20 minutes to check the pain level again." Explanation: Oral pain medicine takes about 45 minutes to digest and take effect; then it peaks in 1 to 2 hours. Before dosing again, the nurse would give the medicine time to work and then reassess the pain. Stating additional pain medication cannot be given for safety is a correct response; however, the best response is to provide the parent information about the client's current pain situation. Telling a parent to be patient will not diffuse the parent's anger. Putting the parent off will only intensify the situation.

A nurse is interviewing the mother of a sleeping 10-year-old girl to assess the level of the child's postoperative pain. Which comment should trigger additional questions and necessitate further teaching?

"She is asleep, so she must not be in pain." Explanation: Just because the girl is sleeping does not mean she is not in pain. Sleep may be a coping strategy or reflect excessive exhaustion due to coping with pain. An easy-going temperament and the ability to articulate how she feels will be helpful for the nurse to establish a baseline assessment. If the girl had never had surgery before, she is less likely to have previous memories or episodes of prolonged or severe pain.

An adolescent has been injured while playing sports. The adolescent describes only minimal pain but the nurse observes clenched fists, rapid breathing and increased muscle tension. Which approach would be best to offer this adolescent pain medication?

"Sports injuries can be very painful. Reducing the pain can help in the healing process." Explanation: Adolescents have problems with accepting pain because of body image concerns and fear of losing control. They fear their behavior will make them look juvenile and thus try to remain stoic and not exhibit emotion. The nurse should address these concerns by being very matter-of-fact and truthful. The nurse can validate the adolescent's pain by stating the injury will cause pain. Explaining that reduction in pain can help in healing is a positive way to offer the pain medication and not make the adolescent appear to lose control. Telling the adolescent pain medication is available or that the adolescent should ask for medication can prolong the pain as the adolescent may be embarrassed to ask because of not wanting to risk being seen as weak or childish. Pain medication should be administered for pain, not as a relaxing agent to be used for treatment.

The nurse is providing family education for the administration of ibuprofen. Which response indicates a need for further teaching?

"This can be taken with other medications we have at home that didn't require a prescription." Explanation: The nurse must emphasize that the parents should carefully read labels of over-the-counter medications they already have or will purchase. Some may contain ibuprofen or other nonsteroidal anti-inflammatory drugs, and if given in conjunction with ibuprofen may lead to overdose. The other statements are correct.

The nurse is caring for a 17-year-old child who has sprained her ankle. The physician has prescribed ibuprofen to manage the pain. What statement by the adolescent indicates the need for further instruction?

"This medication should be taken on an empty stomach." Explanation: Ibuprofen belongs to a group of medications referred to as nonsteroidal anti-inflammatory drugs. Side effects of this medication may include nausea, vomiting, bleeding gums, and bruising. Taking this medication with food may help to lessen gastrointestinal upset.

The nurse is caring for a 9-year-old boy with episodes of chronic pain. The nurse is educating the parents how to help the child manage pain nonpharmacologically. Which statement indicates a need for further teaching?

"We should start the method after he feels pain." Explanation: The parents must understand that they should begin the technique or method chosen before the child experiences pain or when he first indicates he is anxious about or beginning to experience pain. The other statements are accurate.

The nurse has provided teaching of nonpharmacologic pain management to the parents of a 3-year-old child experiencing postoperative pain. Which comments by the parents indicate that the teaching was effective? Select all that apply.

-"I'm not sure if I am imagining it, but I think my child seems to be in less pain when I rock her." -"My child seems to cry a lot less with medical procedures if we are reading a book together." -"One of the nurses blows bubbles with our child every time she is preparing to perform a procedure, then allows our child to do the same during the procedure. It really helps." -"I try to remind our child to think about our dog at home. Our dog is like a big cuddle toy to our child." Explanation: Common behavioral-cognitive strategies of nonpharmacologic pain management that have been found to be effective include relaxation, distraction, imagery, biofeedback, thought stopping, and positive self-talk. Pharmacologic pain management is not always more effective than nonpharmacologic pain management. Various techniques may be available to assist in managing mild pain in children or to augment the effectiveness of medications for moderate or severe pain.

The nurse is reviewing literature about pain management in children. Which statement(s) would the nurse identify as a misconception regarding pain in children? Select all that apply.

-Newborns typically do not feel pain due to immature nerve patterns. -Opioid pain medications should not be prescribed for young children due to side effects. -Children will be truthful when asked if they are experiencing sensations of pain. -Behavioral cues often correlate accurately with the intensity of the child's pain . Explanation: Misconceptions about pain and pain management in children often lead to undertreating pain in children. Newborns have the same pain sensations as adults. The side effects of opioid pain medications are the same for infants, children and adults when used in appropriate doses. Children may deny pain even when they have pain, to avoid an injection, taking medication or a procedure related to pain control. Children may fear pain is a punishment so they will not be truthful when asked about pain. Nurses may underestimate a child's pain level based on behavioral cues. A child who is sleeping or playing may still be feeling pain and playing or sleeping is used as a coping strategy.

The nurse wishes to reassure a 3-year-old girl that there will be no discomfort when her peripheral IV site is examined. The nurse will use which words? Select all that apply.

-no hurt -no owie -no boo-boo Explanation: Children at 3 years will spontaneously use the word "hurt." Other common words for pain used by toddlers or young preschoolers are "owie" and "boo-boo." Children tend not to use the word "pain" until around 6 years of age. A child age 3 would not understand the word "discomfort." This word could be used for an adolescent. Individual children will have their unique descriptors for pain. Nurses need to know these and use them when assessing for pain.

A 7-year-old boy tells the nurse that his head sometimes hurts after he eats ice cream. The nurse recognizes that this type of pain is:

Acute referred pain Explanation: Acute pain means sharp pain, as is the case in this scenario. It generally occurs abruptly after an injury. The pain of a pin prink is an example. Chronic pain is pain that lasts for a prolonged period or beyond the time span anticipated for healing. Referred pain is pain that is perceived at a site distant from its point of origin. In this case, the typical ice cream "brain freeze" is a headache that results from the contact of the cold ice cream with the digestive tract.

The nurse is caring for several pediatric clients on the surgical unit. Which client(s) would the nurse consider a candidate for using patient-controlled analgesia (PCA)? Select all that apply.

An 8-year-old child who is currently in the care of a foster family A 7-year-old child under the custody of the grandparent as medical guardianship Explanation: A patient-controlled analgesia (PCA) pump is appropriate in children 6 to 7 years old or older with age appropriate development. The child needs to be assessed for ability to understand the pump and demonstrate correct use. Children with developmental delays, younger than the age of 6 or 7, or who are unable to communicate their needs are not able to use the pump. Being in the foster system and having the grandparent as guardian would not impede the use of PCA.

A nurse is explaining to a parent about avoiding the use of aspirin for pain relief for flu-like symptoms. Which rationale does the nurse provide?

Aspirin with the flu can lead to Reye syndrome. Explanation: Children should not receive acetylsalicylic acid (aspirin) for pain relief, especially in the presence of flu-like symptoms, because there is an association between aspirin administration and the development of Reye syndrome, a severe neurologic disorder. Although aspirin is irritating to the stomach, that is not the reason for children avoiding aspirin. Guillain-Barré syndrome is not related to aspirin administration. It is important to explain to parents why aspirin is unsafe.

The nurse is caring for children on a postoperative unit. Which nursing action promotes the most efficient pain control?

Anticipate when pain will occur and plan interventions to prevent it. Explanation: The mark of efficient pain control is to anticipate when pain will occur and plan interventions to prevent it rather than let it occur and then relieve it. Three common reasons why nurses and other pediatric providers may not provide adequate pain relief to children include a belief that infants and young children do not experience pain, a fear children will become addicted to pain relief medications, and a fear of causing respiratory depression from analgesics. Infants and young children do experience pain, and there is little chance that children receiving opioids during a short hospital stay will become opioid dependent or that opiates cause greater respiratory depression in children than in adults (Fanning, Stucke, Christensen, et al., 2012). It is helpful to have parents notify the nurse if the child's pain worsens, as well as to assess pain using a standardized tool. However, it is better to anticipate pain and prevent it than to just assess and relieve it.

The nurse is caring for a 7-year-old child who injured the left foot in a bicycle accident. Upon assessment the nurse notes edema of the left foot. The child states the area has mild pain. Which nursing intervention(s) will the nurse include in the child's plan of care? Select all that apply.

Apply an ice pack to the site. Elevate the extremity on a pillow. Explanation: The nurse would apply ice and elevate the extremity to assist in decreasing swelling and pain. Soaking in water could lead to skin breakdown and subsequent infection. Massaging and performing acupressure could both lead to increased pain and would be avoided.

The nurse is reviewing the care plan and records of a 14-year-old on the oncology unit who is receiving opioid pain medication. The client normally has a bowel movement on a daily basis, but the client is at tisk for constipation related to opioid analgesic agents. What would be the best goal for this client's risk?

Client will have a soft, formed bowel movement daily. Explanation: Since the client's normal bowel pattern is daily, the most measurable goal describes the characteristics of normal stools on a daily basis. The other options are not measurable, making it impossible to measure during the evaluation phase of the nursing process.

The nurse is aware of the special needs of children related to pain assessment. What is the priority for the nurse to consider when completing a pain assessment?

Developmental age of child Explanation: Although all of the options are important for assessing pain in children, the priority to provide an appropriate pain assessment is knowing the developmental age of the child. The chronological and developmental ages may differ and care needs to be based on both, but the type of pain assessment tool used will be based on the developmental age. For children who are nonverbal the nurse needs to also consider the parent's statement of pain in the child.

The nurse is caring for an infant who was injured in a severe automobile accident. The child experienced several fractures and is in significant pain. The child's mother questions if this will impact her child later in life. What information should be provided by the nurse?

Experiences with pain even in infancy can influence an individual's response to pain later. Explanation: Repeated exposure to painful procedures and events can have long-term consequences. Memories of pain may be stored in the child's nervous system, influencing later reactions to painful stimuli.

When educating a parent on how to support the child while experiencing a painful procedure, what is the best information for the nurse to convey?

Explain in detail the role of the parent as a coach and emphasize the coping plan. Explanation: The question asks for the best information, which is having the parent understand his or her role. Parents have a strong influence on the child's ability to cope. For example, if a parent reacts to the child's pain in a positive manner and offers comfort measures, the child may have an easier time coping. If the parent shows anger or disapproval, the pain experience may be intensified for the child. The nurse should break down complex procedures into specific steps and reinforce coping strategies for each distinct task. To do this, the nurse should model, or demonstrate, coping behaviors as well as detail the parent's coaching role and reinforce the need for the parent to emphasize the coping plan, rather than apologizing for the pain. Although parents want to help their children and some are able to act as coaches, the response of the child to pain and stress and to the parents' distraction interventions is highly variable. Some children appear to be soothed by their parents' distraction actions; others appear to become distressed. Thus, the parents should be prepared that they may need to step away from the child. The parents should be focused on the coping plan, not on the procedure itself. Focusing on the procedure attracts the child's attention to the negative experience.

The nurse is caring for a 12-year-old with cerebral palsy who is unable to communicate verbally. Which pain assessment tool is the most appropriate for the nurse to use when assessing pain in this client?

Face, leg, activity, cry, and consolability (FLACC) descriptors Explanation: If the child has cognitive deficits, use tools for pain assessment that are appropriate for developmental level. Do not use chronologic age as a basis for pain assessment. When the child is unable cognitively to communicate pain, assessment methods used for infants may be employed, such as a FLACC scale. Use of a pain diary requires handwriting skills and use of a numeric rating scale or APPT scale requires verbal and/or cognitive skills.

The nurse is preparing a 6-year-old child for a bone marrow biopsy. The child is very anxious about going through this procedure. Which nursing diagnosis best fits this situation?

Fear related to anticipation of painful procedure Explanation: Fear related to anticipation of painful procedure is the most appropriate nursing diagnosis for this situation because the child is anxious about the painful procedure. The child is not experiencing pain yet, nor is the child trying to sleep.

Which nursing intervention demonstrates proper use of cutaneous stimulation to relieve pain in pediatric clients?

Gently massaging a preterm infant's leg for 2 minutes prior to obtaining a blood sample from a heel stick. Explanation: Gentle massage of the leg for 2 minutes prior to heel stick may decrease pain response in preterm infants. Massage and pressure relax the muscles and decrease the tension. It also increases blood flow to the area. Use of heat or cold therapy is contraindicated in infants, who are more prone to thermal injuries. Ice packs should not be used for longer than 15 minutes at a time. Heat is most effective in relieving pain from inflammation and spasm.

The nurse is providing postsurgical care for a 4-year-old boy following hernia repair. Before surgery, the nurse taught the child to use the poker chip tool to rate his pain. When assessing the child's postsurgical pain, the boy refuses to touch the chips and clings to his mother. How should the nurse respond?

Give the mother the FACES pain rating scale to use with her son. Explanation: Different pain rating scales are appropriate for different developmental levels. Children often regress when in pain, so a simpler tool such as the FACES scale may be needed. It is also helpful to enlist the assistance of the parent. Expecting the child to select a chip is developmentally inappropriate when the child shows signs of regression. The child wouldn't understand the phrase "word-graphic scale," and this scale or the visual analog scale is more complex than this 4-year-old can handle.

The nurse wishes to use a distraction technique when administering an injection to an anxious school-aged child. Which technique should the nurse implement?

Have the child blow bubbles. Explanation: Behavioral-cognitive strategies are useful for pain management in many ways and forms. They involve measures requiring the child to focus on a specific area rather than the pain. A distraction technique helps the child focus on another stimulus. Examples of this are counting, saying ouch, blowing bubbles, and music. Having a child create a mental image of something pleasant is a form of imagery. Using controlled deep breathing is a form of relaxation. Teaching the child to make positive statements such as "it will be over soon" is a form of thought stopping.

The nurse is caring for a 5-year-old child who underwent a painful surgical procedure earlier in the day. The nurse notes the child has not reported pain to any of the nursing staff. Which action by the nurse is indicated?

Observe for behavioral cues consistent with pain. Explanation: Children may underreport feelings of pain. They may assume that adults know how they are feeling or they may feel worried about appearing to lose control. The nurse should assess for the presence of behavioral cues that might be consistent with pain. The nurse should not simply administer analgesics without cause.

The nurse is teaching the parents about children and pain. Which statement indicates understanding of this teaching?

Opioids can be safely used with children. Explanation: In the proper dosage, opioid can be safely used with children, even premature infants. However, it has been proven that infants do experience pain. Sometimes, children in pain will sleep due to the exhaustion from the pain. Also, children may fear expressing pain due to not wanting an injection or trying to be brave.

The pediatric nurse is mentoring a new graduate in the care of children experiencing pain. The nurse knows the teaching was effective when the new graduate makes which statement as the rationale for considering pain assessment?

Pain assessment needs to be done at regular intervals. Explanation: Pain assessment is so important that it should be done at regular intervals. Nurses do not forget to assess pain, but it is important to include it with each assessment. It is not possible to keep children free of pain, but it is important to assess it regularly and help relieve the pain as much as possible.

What behavioral responses to pain would a nurse observe from an infant younger than age 1?

Reflex withdrawal to stimulus and facial grimacing Explanation: Infants younger than age 1 become irritable and exhibit reflex withdrawal to the painful stimulus. Facial grimacing also occurs. Localized withdrawal is experienced by toddlers ages 1 to 3 in response to pain. The nurse would observe passive resistance in school-age children. Preschoolers show a low frustration level and strike out physically.

The nurse is working with the mother of a 6-year-old girl to think of an effective means of distracting the girl from a painful procedure that she will shortly undergo. To be effective, the distraction technique must have which characteristics?

Requires concentration of the child Explanation: When helping parents choose a distraction technique such as blowing soap bubbles with their child, be certain they do not interpret "distraction" as just talking to the child or suggesting a video game to divert attention. Although these are distractions, a distraction activity must require concentration; simple distractions can allow pain to break through. The other answers listed are not necessary as a part of distraction techniques.

A nurse is caring for a 4-year-old child who is exhibiting extreme anxiety and behavioral upset prior to receiving stitches for a deep chin laceration. Which nursing intervention is a priority?

Serving as an advocate for the family to ensure appropriate pharmacologic agents are chosen. Explanation: When a child is manifesting extreme anxiety and behavioral upset, the priority nursing intervention is to serve as an advocate for the family and ensure that the appropriate pharmacologic agents are chosen to alleviate the child's distress. Ensuring emergency equipment is readily available and lighting is adequate for the procedure is also part of the nursing function, but secondary interventions. Conducting a baseline physical assessment is important but would likely be difficult if the child was crying inconsolably or was extremely anxious.

The nurse is caring for a 3-year-old child who has an intravenous line. When medications are delivered through the line the child experiences burning. What action by the nurse will be most helpful?

Sit with the child and use distractions such as toys during the infusion. Explanation: Some medications cause discomfort and burning when they are administered intravenously. Sitting with the child and providing distraction such as with toys will help distract the child during the infusion. Topical anesthetic agents may be used prior to the initiation of the intravenous device. It is not used once the IV line has been started. Telling a 3-year-old child that the medications will make him or her better is not going to be an age-appropriate means to deal with the discomforts of the medication administration. It is not realistic that the medication can be scheduled for administration when the child is sleeping.

A young child is in the emergency department with swelling and pain in the right ankle. The client states that while playing soccer, she somehow twisted her ankle and could not walk off the field. The health care provider tells the client that it is a sprain. Which type of pain is this client experiencing?

Somatic Explanation: Pain is classified in two categories. Acute pain has a rapid onset, usually as a result of tissue injury and it resolves with the injury healing. The other type of pain is chronic. This type does not end when the injury heals and affects a client's activities of daily living. One type of acute pain is somatic pain. Somatic pain originates from deep body structures, such as muscles or blood vessels. The pain of a sprained ankle is somatic pain. Visceral pain is pain occurring in the organs. Cutaneous pain affects the skin.

A parent expresses concern to the nurse that her 18-month-old child might have an ear infection. Which symptom would alert the nurse that this is a possibility?

The child is pulling on the ear. Explanation: Pulling on the ears is a typical symptom of an ear infection in a preschool child. Nonstop crying is not necessarily related to the ear, nor is an elevated temperature. An 18-month-old would not be able to express having an "ouchie" in his ear.

The nurse teaches a preschooler to use a FACES pain rating scale prior to surgery. At that time, the preschooler points to the smiling face. Following surgery when the nurse suspects the child has pain, the preschooler points again to the smiling face. How would the nurse interpret this response?

The child is using the scale to predict what they would like, not what the child has. Explanation: Preschoolers use "magical thinking," or believe that what they wish will come true. They may use pain scales, therefore, to "wish" for a smiling face, rather than for rating their pain. Preschoolers also may not report pain, thinking it is something to be expected. If the child does not report pain then the nurse should also assess the child's features: Is the child grimacing, crying, or being totally still? The nurse can also ask the parent if this is how the parent would describe the child when in pain. Pain is subjective so the nurse would not be reporting the pain falsely.

A six-year-old child is observed sucking the thumb and baby talking while hospitalized for cellulitis. How would the nurse explain this to the parents?

The child may be in pain. Explanation: Some children of school age will regress with pain such as returning to baby talk, thumb sucking, or lying in a fetal position. This child is not seeking attention, acting out, or appearing to be fearful of the nurse.

The nurse working in the emergency department is caring for an 8-year-old boy who was hit by a car while running across the street and has suffered extensive abrasions, contusions, and broken bones. IV morphine analgesia has been given. The child is unable to follow simple directions to allow for procedures to be completed. What is the best action to take for this child?

The child should be sedated. Explanation: If a child is unable to follow directions and allow a procedure to proceed safely with analgesia alone, the child should be sedated. Children are routinely restrained without sedation or analgesia for painful procedures, something that would be unthinkable with an adult. This would not be an appropriate intervention. The child is in too much pain to understand an explanation at this point.

The nurse is caring for a 2-year-old child who has been hospitalized after being injured in an automobile accident. During the assessment the child is quiet and watchful of all the nurse's actions. When considering the level of pain being experienced by the child what inference can be made?

The child's nonverbal behaviors may indicate the presence of discomfort. Explanation: Responses to pain can vary in children. A child of this age may present with vocal behaviors indicating pain. The child may be tearful or crying loudly. Being quiet can also signal pain.

A 12-year-old girl needs a lumbar puncture to collect cerebrospinal fluid for a laboratory exam plus injection of medication into the central nervous system. She expresses great fear of the procedure because of anticipated pain and the inability to hold still. The nurse contacts the physician to make which suggestion?

The use of conscious sedation for the lumbar puncture. Explanation: The nurse recognizes the child's fear and is acting as her advocate suggesting the use of conscious sedation. It will be the most effective way to relieve the child's anxiety, pain, and concern about cooperation. A medication given for anxiety prior to the procedure may ameliorate some stress and make lying still a bit easier but will not relieve pain. Support from parents and a child life specialist is helpful and can be part of the conscious sedation plan. Alone it would not be adequate to assist the child. Delaying the procedure to do additional teaching could be helpful in some situations but is not the best choice here.

A nurse is admitting a 5-year-old hospitalized child with normal speech and verbal development. Which pain scale will the nurse use to assess this child?

Wong-Baker Faces Pain Rating Scale Explanation: The FACES pain scale is an appropriate scale for children 3 years and older to rate their pain using a range of cartoon-like faces. The CRIES and COMFORT pain scales are intended for neonates and are not appropriate for a 5-year-old child. The FLACC pain scale measures nonverbal responses when the child cannot provide input and is not the appropriate choice for this child.

A nurse is caring for a child who is grimacing but reports having no pain. What might be the rationale for a child being reluctant to express pain?

fearing getting a "shot" to relieve the pain Explanation: The nurse should be aware that some children may be reluctant to admit pain because they are trying to be brave. Some may be reluctant to say they have pain because they are afraid they will receive a "shot" to relieve it, which will cause more pain. Although children may not know how to express pain, it is still important to assess their pain level. Anxiety about pain may be high, but it does not prevent children from trying to express it.

A child has been admitted to the emergency department with a pneumothorax. Which intravenous medication prescription does the nurse select prior to the insertion of a chest tube in the child?

fentanyl Explanation: Fentanyl has a shorter duration of action than morphine, methadone, and hydromorphone but works quickly and produces fewer side effects such as pruritus and vasodilatation. These features make it an ideal drug to use for short, painful procedures, such as debriding a burn or inserting a chest tube to relieve a pneumothorax.

A nurse is providing immunizations to a 5-year-old client. What strategy uses the gate-control theory of pain to reduce immunization pain for this client?

having child count during administration of the immunization Explanation: Distraction, such as counting, is a strategy that reduces the transmission of pain impulses to the brain. Closing the eyes and holding the breath may increase anxiety and increase pain, and looking at the needle may also increase anxiety and pain. Acetaminophen is pharmacologic pain relief, not based on gate-control theory. Additionally, acetaminophen is unlikely to be effective or necessary for short-term pain that accompanies injection with immunization.

The nurse is caring for a 3-year-old client following a Fontan procedure to repair a hypoplastic left heart (above). What assessment finding(s) by the nurse indicates the child may be in pain? Select all that apply.

heart rate diminished breath sounds guarding and moaning blood pressure Explanation: The child may exhibit increased heart rate and blood pressure in response to pain; both of these values are elevated for a 3-year-old child. The diminished breath sounds may also indicate pain, as the child does not take a deep breath due to pain. Guarding and moaning are also common signs of pain. The skin color is normal and does not indicate pain. In addition to the subjective observation of potential pain symptoms, the child should consistently have the pain assessed using a standardized scale.

An adolescent is experiencing severe pain due to a sickle cell crisis. Which medication would be best for the nurse to administer?

hydromorphone Explanation: For managing severe or acute pain, such as postoperative pain or the pain of a sickle cell crisis, opioids (e.g., morphine, oxycodone, and hydromorphone) are frequently prescribed. NSAIDS and acetylsalicylic acid would not help severe pain.

A nursery nurse is explaining to a new parent about how to assess the newborn for pain. Which manifestation indicates that an infant is in pain?

inability to be consoled Explanation: Crying, chin quivering, and a high pitched cry could be due to pain, but they can also be due to other situations. However, when an infant cannot be comforted or consoled, it is usually due to pain.

Which type of medication lacks a ceiling effect, and therefore is prescribed in initial doses that must be titrated to achieve pain relief while managing side effects?

morphine Explanation: A ceiling effect is when a dosage of a pain medication is frequently increased but smaller and smaller gains are made to reduce the pain. The severity of the side effects also increases as the dosage is increased. Mixed-agonist-antagonists have a ceiling effect. Pure opioid agonists (morphine, hydromorphone, fentanyl) do not have a ceiling effect. They can be given in initial dosages and as needed without having to increase the dose to gain pain relief. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, and aspirin have ceiling effects. Each has recommended dosages not to be exceeded every 24 hours.

A 10-year-old child is scheduled for open reduction and internal fixation of the tibia following a skateboard accident. The nurse anticipates which pain medication and administration method will best provide postsurgical pain relief for this child immediately after surgery?

morphine given as an intravenous injection Explanation: For managing severe or acute pain, such as postoperative pain, opioids like morphine or fentanyl are preferred. Immediately after surgery, the intravenous route is preferable to the oral route because the child may not be able to tolerate oral medications at that time and intravenous medications begin to work much faster than oral medications. NSAIDs, such as ibuprofen or naproxen, are excellent for reducing pain because they reduce inflammation and pain; however, the child most likely will not be able to take an oral medication immediately following surgery. NSAIDs could be given intravenously as prescribed during the immediate postoperative period. Intramuscular injections should be avoided in children because the number of suitable injection sites in children is limited, injections are associated with pain on administration, and many children are afraid of injections. As a rule, other routes for administration of pain medication are used whenever possible.

The 5-year-old client is hospitalized for a femur fracture and awaiting open reduction and internal fixation (ORIF) surgical repair (above). What medication should the nurse administer based on this client's assessment?

naloxone Explanation: The child is exhibiting signs of excessive sedation and respiratory depression after the dose of intravenous morphine. Naloxone, an opioid antagonist, should be administered to counteract the effects. Morphine and fentanyl would increase respiratory depression and are not appropriate choices. Midazolam would also increase sedation and would not counteract the respiratory depression.

A nurse is working on a pediatric postoperative unit. Which pain assessment method is best for the nurse to use with an adolescent to determine severity of pain?

numerical Explanation: Adolescents are able to use adult numerical pain scales for assessment of pain severity. FLACC scale is used with infants and Wong-Baker FACES scale is used with younger children. A description does not address pain severity.

The neonatal nurse is preparing to perform a heel prick for blood work on a 3-day-old infant. Which procedural pain management will the nurse provide the client?

pacifier with oral glucose Explanation: Oral glucose has been demonstrated to provide effective pain relief to infants undergoing painful procedures. It provides both distraction and the release of endorphins and an analgesic effect. Looking at images or singing a lullaby are not effective distractions for pain management for a 3-day-old infant. Acetaminophen is longer acting and is not necessary or effective for mild, short-term procedural pain for an infant of this age.

A young child is hospitalized with pneumonia. Upon admission the client states not having pain but just a bad cough. A few hours later, the child he begins reporting pain in the right lower back. This first report of feeling pain refers to:

pain threshold. Explanation: Pain threshold refers to the point at which the child first feels the pain. The pain tolerance refers to the maximum level of pain a person can tolerate. Usually, this is measured on the analog scale. The duration of pain indicates how long the pain has been occurring. For example, if the pain is postoperative it is referred to as acute pain. If it has been occurring for 3 months and is persistent it is considered chronic pain. The pain peak is when the client describes the pain at its worst. Depending on the problem that may be minutes, days, or months. For example, a client may have a condition where the pain is worse on day 3 of the illness instead of day 1.

The nurse is preparing to use the FLACC behavioral scale to assess the pain level of a child. For which child will the use of this scale be the most appropriate?

postoperative 6-year-old child who is unable to accurately report pain level Explanation: The FLACC behavioral scale is a behavioral assessment tool that is useful in assessing a child's pain when the child is unable to accurately report his or her level of pain or discomfort and is reliable for children from age 2 months to 7 years. A 7-year-old child who is getting ready to undergo a dressing change and a 4-year-old child who just had stitches placed would be able to report pain and could use the Faces, Oucher, poker chip, or visual analog scales. A 10-year-old with a broken femur in traction would be able to self-report pain using the numeric scale. In alert children verbally able to report pain, self-report is the primary source for the measurement of pain.

The nurse is caring for a child who has received postoperative epidural analgesia. Which nursing assessment is priority?

respiratory depression Explanation: Respiratory depression, although rare when epidural analgesia is used, is always a possibility. However, when it does occur it usually occurs gradually over a period of several hours after the medication is initiated. This allows adequate time for early detection and prompt intervention. The nurse should also monitor for pruritus, urinary retention, and nausea and vomiting but the priority is to monitor for respiratory depression.

Which statement is the goal of distraction techniques used to control pain?

to divert the child's attention away from the pain through controlled, purposeful behaviors Explanation: The goal of distraction interventions is to divert the child's attention away from the pain through controlled, purposeful behaviors. These behaviors assist in managing mild pain or to augment the effectiveness of pain medication for moderate to severe pain. Distraction interventions assist children to cope with pain and gives them a sense of mastery or control over the situation. Distraction interventions will not take the pain away nor is their purpose to reduce the amount of or not give pain medication. The goal of distraction interventions is not parent-focused and the purpose is not entertainment for the child.

The nurse is preparing to administer a dose of ketorolac to a 15-year-old adolescent. How should the nurse administer the medication to reduce the potential for gastrointestinal upset?

with meals Explanation: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID). It is associated with gastrointestinal upset. To reduce this side effect the nurse may administer the medication with food.