Chapter 5: Pain Assessment and Management in Children

The physician has ordered the postoperative four-year-old child to receive hydromorphine (Dilaudid) intravenously. The drug book lists a therapeutic range for Dilaudid to be 0.01 to 0.015 mg/kg/dose every three to four hours. What would be the maximum therapeutic dose of Dilaudid if the child weighs 30 pounds? Round your answer to the nearest hundredth.

0.2 mg

The clinical nurse specialist is concerned about children's reactions to painful invasive procedures such as intravenous starts. The nurse has decided to use distraction as a means to comfort the school-age child. Depending on the age of the school-age child, which technique might the nurse use to distract the child? (Select all that apply.) A. Blowing bubbles B. Music therapy C. Guided imagery D. Hypnosis E. Sucrose solution

A. Blowing bubbles B. Music therapy C. Guided imagery Blowing bubbles or popping bubbles can be a distraction for a young school-age child. Listening to music or singing can be used as distraction for this age group. Guided imagery is a means of encouraging relaxation and mental images to manage pain. Under hypnosis, the child is an altered state of awareness; this is not a form of distraction. Sucrose solution is used for infants up to 12 months of age. It has not been found to be effective in the school-age child.

A nurse is taking care of a patient in the ICU who has been on opioids for an extended period of time. The nurse understands that the child has to slowly wean from the medication over a period of time. While weaning, the nurse will observe the child for symptoms of too rapid withdrawal, including: A. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps B. Bradycardia and pallor C. Decreased blood pressure and drowsiness D. Voracious appetite and hypotonicity

A. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps These are symptoms of withdrawal resulting from reducing the dose too quickly. A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating. The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful. Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal.

The nurse is caring for a four-year-old child who is intellectually disabled and is scheduled for surgery tomorrow. The nurse wants to plan postoperative care and pain relief. The nurse will determine the best pain assessment tool by observing the child's: (Select all that apply.) A. Language skills B. Understanding of the concept of more and less or otherwise has the ability to quantify pain C. Ability to sit for a ten minute evaluation D. Ability to perceive pain E. Ability to understand pain

A. Language skills B. Understanding of the concept of more and less or otherwise has the ability to quantify pain In order to report pain, the child needs adequate verbalization skills to communicate to the nurse. The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale. The assessment does not require the child to sit still. Children perceive pain. The issue is if the nurse can recognize the child's pain. Children do not need to understand pain in order to feel pain.

The nurse is taking care of a seven-year-old child who is postoperative. The child's mother requests that the child not receive narcotics in the postoperative period because she is afraid the child will become addicted. The nurse would explain to the mother that children who do not receive adequate pain control will be at risk for: A. Respiratory complications B. Urinary complications C. Cardiac complications D. Bowel complications

A. Respiratory complications The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory complications. Uncontrolled pain does not usually lead to urinary complications. Uncontrolled pain does not lead to cardiac complications. Uncontrolled pain does not frequently lead to bowel complications.

The nurse is working in a pediatric surgical unit. The nurse would expect that patient-controlled analgesia would be most appropriate for which patient? A. Twelve-year-old who is postoperative for spinal fusion for scoliosis B. Ten-year-old who has a fractured femur and concussion from a bike accident C. Five-year-old who is postoperative for tonsillectomy D. Developmentally delayed 16-year-old who is postoperative for bone surgery

A. Twelve-year-old who is postoperative for spinal fusion for scoliosis Patient-controlled analgesia is most appropriate in children five years old and older. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. Children who have suffered head trauma would not be candidates for PCA. PCA generally is prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed would not be candidates for PCA.

The nurse is caring for a child who has been sedated for a painful procedure. What is the priority nursing activity for this child? A. Place the child on a cardiac monitor B. Allow parents to stay with the child C. Monitor pulse oximetry D. Assess the child's respiratory effort

D. Assess the child's respiratory effort When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. The nurse should: A. Reassess the child in 15 minutes to see if the pain rating has changed B. Administer the prescribed analgesic C. Do nothing, since the child appears to be resting D. Ask the child's parents if they think the child is hurting

B. Administer the prescribed analgesic School-age children are old enough to report their pain level accurately. A pain score of six is an indication for prompt administration of pain medication. The child might be trying to be brave or might be lying still because movement is painful. There is no need to reassess, as the child needs pain medication now. The child might be lying quietly because movement increases the pain. The school-age child can answer for herself and does not need the parents to answer for her.

In responding to the needs of pediatric patients in pain, the nurse has numerous nonpharmacologic interventions available. These interventions include: (Select all that apply.) A. Regional nerve block B. Cutaneous stimulation C. Application of heat D. Electroanalgesia E. Use of EMLA cream

B. Cutaneous stimulation C. Application of heat D. Electroanalgesia Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain. The use of heat (and cold) may help reduce pain sensations and utilizes no pharmacologic agents. Electrical stimulation to the skin uses the gate control theory to relieve pain. A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief. EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method.

A five-year-old is hospitalized with a fractured femur. Which assessment tool is appropriate for this child? A. CRIES Scale B. Faces Pain Rating Scale C. SUN Scale D. PIPP Scale

B. Faces Pain Rating Scale A five-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. The CRIES Scale was developed for preterm and full-term neonates. The SUN Scale was developed for use in newborns. The PIPP Scale was developed for premature infants.

The 17-month-old infant is terminally ill with cancer and is in constant pain. The nurse recognizes that the best way to control pain in this child would be for the physician to order: A. Patient-controlled analgesia with the parents controlling the button that administers the dosage B. Intravenously administered opioids on a scheduled basis C. Intravenously administered opioids on a prn basis D. Parenteral administration controls pain more effectively than oral medication as oral absorption may be modified by stomach activities. In addition, providing analgesics on a scheduled basis is preferred over prn

B. Intravenously administered opioids on a scheduled basis This provides continuous blood levels of the opioid. PCA should always be controlled by the individual receiving the medication. It is inappropriate to have the parents control the medication administration. By waiting until symptoms are present, the child's blood level will drop, making it more difficult to control the pain.

The nurse is preparing to perform a heel stick on a neonate. The most appropriate complementary therapy for the nurse to plan to use in the neonate to decrease pain during this quick but painful procedure is: A. Holding the infant B. Sucrose pacifier C. Massage D. Swaddling

B. Sucrose pacifier Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain.

A five-year-old child is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching? A. "I will call the office tomorrow if the pain medicine is not relieving the pain." B. "I can expect my child to have some pain for the next few days." C. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." D. "I will plan to give my child pain medicine around the clock for the next day or so."

C. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." Increasing pain can be a sign of complication and should be reported to the physician; therefore, the nurse should clarify expectations for pain control. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified. This statement indicates the parent understands and does not need additional teaching. The child is expected to have some pain for a few days after surgery. This statement indicates the parent understands the teaching. The child should receive pain medication on a scheduled basis. This statement indicates the parent understands the teaching.

A hospitalized three-year-old needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which is the most appropriate nursing diagnosis? A. Knowledge deficit of the procedure B. Fear related to the unfamiliar environment C. Anxiety related to anticipated painful procedure D. Ineffective individual coping related to an invasive procedure

C. Anxiety related to anticipated painful procedure This child is not old enough to understand the need for an IV infusion. The question stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The question stem indicates that the child has been through this before, so Knowledge deficit is not the most appropriate diagnosis. The child's fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick. The child's behavior is appropriate for coping in this age child.

A six-year-old postoperative patient IV has infiltrated and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. What other complementary therapies would be most helpful when placing this IV? A. Restraints B. Moderate sedation C. Anesthesia D. Distraction

D. Distraction Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure. Restraints are used only as a last resort and are not appropriate for an IV start. Moderate sedation has its own side effects and possible complications and should not be used for quick procedures. Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture.

An analgesic is ordered for a post-surgical patient to be given every three to four hours. The nurse knows that a delay in giving the medication will cause a(n): A. Decrease in the chance of withdrawal symptoms B. Decrease in the chance of addiction C. Increase in the chance of breakthrough pain D. Increase in the child's pain tolerance

C. Increase in the chance of breakthrough pain Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning. Delaying the pain medication will not decrease the chance of addiction or increase the child's pain tolerance.

The nurse administered morphine intravenously to a four-year-old postoperative patient. Thirty minutes later, the nurse assesses the child. Which assessment finding requires further evaluation? A. Pulse decreased from 136 to 104 B. Blood pressure dropped from 110/72 to 90/55 C. Respiratory rate went from 42 to 16 D. Child pulls away from nurse who wants to assess surgical site

C. Respiratory rate went from 42 to 16 This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child's respirations are being depressed. The normal pulse rate for children two to five years of age is between 70 and 120. 90/55 is a normal finding for this age group. The child pulling away from the nurse is normal behavior for a four-year-old child.

The nurse is caring for a two-year-old child in the postoperative period. The pain assessment tool most appropriate for assessment of pain intensity in a two-year-old is the: A. Poker Chip Tool B. Oucher Scale C. Faces Pain Rating Scale D. FLACC Behavioral Pain Assessment Scale

D. FLACC Behavioral Pain Assessment Scale The FLACC scale is an appropriate tool for infants and young children who cannot report pain. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children three and older.

The postoperative unit of the pediatric hospital has several children who had surgery this morning. While making rounds, the nurse observes all of the following behaviors. Which child should be further evaluated as to postoperative pain? A. The six-month-old in deep sleep B. The two-year-old who is cooperative when the nurse takes his vital signs C. The four-year-old who is actively watching cartoons D. The 14-month-old who is thrashing his arms and legs

D. The 14-month-old who is thrashing his arms and legs Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing their arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability. Children are unable to obtain deep sleep when experiencing acute pain. When experiencing acute pain, children are less likely to cooperate with treatments. It is difficult for children to concentrate when experiencing acute pain.

During shift report, the night nurse reports that the child who is terminally ill has developed tolerance to the morphine that the child has been receiving. The oncoming nurse realizes that the child: A. Is physically dependent on morphine B. Is addicted to morphine C. Is showing physical signs of withdrawal D. Will need more medication to achieve the same effect

D. Will need more medication to achieve the same effect Tolerance occurs when the body has become accustomed to the presence of the drug in the system. When this happens, the child will need more of a drug or a stronger drug to get the same effect. While the child may be physically dependent, this is not the meaning of tolerance. Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance. Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance.