Pain Assessment in Children

Pain Assessment

Pain history How does the child typically express pain - Run and hide? What are the child's previous experience with pain What works to reduce the child's pain - Blankie? Parent and child's preference for analgesic use and other pain interventions - What do you already have established? Memories of past pain can trigger anxiety that elevates the pain response.

Children and Pain

Children may not complain of pain - Due to limited vocabulary and experience - In an effort to be brave - Because they assume nurse knows they have pain - Afraid treatment will be worse than pain itself

Pain Scale - Oucher Scale

- 3-13 yrs Six pictures - Available in gender and ethnic versions

Physiologic and Behavioral Consequences of Pain

Behavioral effects Infant Less than 6 months - grimacing, poor feeding - 6 to 12 months - crying, irritability, restlessness Toddlers 1. Aggressive behavior 2. Physical resistance - I don't want to get up I want to stay here. Behavioral effects School age 1. 7 to 9 years - rigid, still, emotional withdrawal - Do not have control over muscle tension cannot relax their arm. 2. 10 to 12 years - may project bravery, may regress - At last minute may cry Adolescents 1. Controlled behavioral response - Can say I need you to relax your arm. 2. May find distraction or deny pain

Oral Administration

Correct dosing - Dosing syringe - Teaspoons are inaccurate - Droppers are good if they come with the medication Dissolved in solution - Usually sweetened - Avoid adding it to large amount of liquid or formula

Pharmacological Therapies

Dosages by weight ALWAYS, ALWAYS, ALWAYS CALCULATE ORDERED DOSE BEFORE ADMINISTERING MEDICATION. QUESTION ANY DOSE THAT IS MORE THAN OR LESS THAN THE EXPECTED DOSE. - May be fine but double check and ask about it.

Numeric Pain Scale

Explain that 0 is no pain and 10 is the worst pain. Have them verbally report or point to a number that is their level of pain - over 5 yrs

How is Children's Pain Different

Like adults, it is what the person tells you it is... Unlike adults children may rate pain differently because of: -Age: they may not have the language skills or localize where the pain comes from. -Developmental stage -Chronic or acute disease depends on how they talk about it. -Prior experiences with pain any previous bad experience will stay with them. -Personality -Family dynamics strong supporting family. -Culture some are expressionist and some are astoic

Nonsteroidal Anti-inflammatory Drugs (NSAIDS)

Medication 1. Acetylsalicylic Acid (Aspirin) given orally - Use for short-term management of mild to moderate pain - Do not use Aspirin in children under 18years 2. Ibuprofen ( Motrin) - Give with food to decrease GI up-set 3. Naproxen (Aleve) - Monitor for prolonged bleeding time 4. Ketorolac (Toradol) given IV - effects to cause kidney failure, deadly. - Liver function tests should be followed if in long-term use

Opioid Administration

Methods of administration - Oral (preferred) - Subcutaneous - Intramuscular - Intravenous (preferred) - Topical

Routes of Administration

Oral- may require higher dosing than parenteral. - preferred due to convenience, cost and maintenance of blood levels - (may take up to 1-2 hours to peak) -not appropriate for children that require rapid pain relief or fluctuating pain Sublingual-faster acting than oral - administration involves placing a drug under your tongue to dissolve and absorb into your blood through the tissue there. IV bolus and continuous dosing (most effective) - IV-can be periodic or PCA pump - rapid control in approx. 5 minutes morphine, hydromorphone continuous: provides steady bloody level IM - IM injection is usually more rapid and predictable than after oral administration. A disadvantage of this route is that the dose maybe too large (side effects) or too small (no pain relief). In addition, the injections are painful and the onset of pain relief is delayed while the drug is absorbed Topical - transdermal - 60 min prior for superficial, 2.5hr prior deep puncture place dressing over cream reddened or balanced skin equals adequate response - effective for long term relief, may take some time to begin. Fentanyl patch. Rectal - many meds are available in suppository form

Pain Scales - FLACC

Originally developed for post-op pain assessment Interpreting the Behavioral Score Each category is scored on the 0-2 scale, which results in a total score of 0-10. 0-Relaxed and comfortable 4-6-Moderate pain 1-3-Mild discomfort 7-10-Severe discomfort

Patient Controlled Anesthesia

PCA are frequently used for postoperative or children in severe pain PCA's in children may be used by - Children over 6 yrs old - Parent or primary caregiver who has been instructed to use it - Nurse caring for child Pain level should be assessed before pushing the button

Pain Assessment in Children

Pain is often considered a fifth vital sign, assessed along with temperature, pulse, respiration, and blood pressure. Because pain can affect patients' physical, emotional, and mental well-being, it must be managed immediately and effectively so that they can perform daily activities.

Nursing Care for Child With Acute Pain

Reassess frequently May not have worked or may have worked too well. Use non-pharmacological and pharmacological or both to manage pain combination of both Ask the caregiver to help reassess the pain level Observe for adverse reactions to pain medicines Assess the child's physical functioning following pain management interventions

Opioid Issues and Treatment

Respiratory Depression/Distress - Antidote: Naloxone Constipation - Diet modification, fiber and fluids Nausea and vomiting - Other meds to help decrease, usually declines after 1-2 days Pruritis (itching) - Anti-itch: Nalbuphine and diphenhydramine

Consequences of Pain

Respiratory changes 1. Stress response - Respiratory - rapid, shallow breathing, inadequate lung expansion and cough -can lead to low O2 sats, atelectasis or pneumonia 2. Neurological changes - Increase in heart rate, blood sugar, cortisol levels - Altered sleep patterns 3. Metabolic changes - Increase in fluid and electrolyte losses 4. Immune system changes - Suppressed immune and inflammatory process causing increased risk of infection, delayed wound healing Gastrointestinal changes decreased gastric acid secretion and intestinal motility

Document Effect of Meds

Use consistent scale to document relief or change in pain Pain should be assessed before and after med is given

Pain Assessment Tools

Various scales and tools have been used to assess pain in children. In order to be accepted as tools, they must have: Validity - accurately measures the concept it was designed to measure Reliability - consistent results are obtained when measured by the same or different raters The following tools have validity and reliability established The first 2 pain scales can also be used for non-verbal patients who are older

Co-analgesics

For symptoms and side effects 1. Diazepam and midazolam (anti-anxiety) 2. Anti-seizure meds for nerve pain.

Neonatal Infant Pain Scale (NIPS)

For infants up to 2 months Pain Level Intervention 0-2 = mild to no pain None 3-4 = mild to moderate pain Non-pharmacological intervention with a reassessment in 30 minutes >4 = severe pain Non-pharmacological intervention and possibly a pharmacological intervention with reassessment in 30 minutes

Types of Pain

Acute - sudden and of short duration. associated with a single event such as surgery, injury or exacerbation of a condition such as Sickle Cell. An immediate pain response that occurs at the time of tissue damage and the inflammatory response that follows. Pain decreases as healing occurs Chronic - persistent, lasting longer than 3 months. usually associated with a prolonged disease process. affects entire nervous system and child has increased neuron responsiveness to painful and non-painful stimuli Recurrent Pain - Pain alternating with non painful episodes. "Sickle Cell Crisis" If pain is untreated or poorly treated, neurons over-react to pain stimulus and initiate a pain memory and potentially permanent alterations in pain pathways of young infants

Pain Scale -Wong Baker Faces Scale-Children 3 and up

Ages 3 and older We use this scale by telling children "These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] - it shows very much pain. Point to the face that shows how much you hurt [right now]."

Nursing Management for Chronic Pain

Assessment - Obtain history, intensity, duration, and so on. - Learn impact on child's daily life. - Identify methods for coping. - Ask about current treatments/complementary and alternative medicine (CAM). - Observe appearance, posture, gait, emotional and cognitive state. - Neurologic exam Pain journal Pain assessment scale Care plan for painful episodes Develop complimentary therapies. Encourage daily exercise.

Nursing Care Plan of Children Experiencing Acute Pain

Assessment 1. Cognitive and developmental status - Can they tell you about the pain or no? 2. Emotional status - Parents there or no 3. Previous pain experience 4. Parental input - What helps to cope with pain? 5. Nonverbal children - Signs of pain. Diagnoses (examples) - Acute pain - Anxiety - Impaired Physical Mobility - Nausea Planning/implementation 1. Pharmacologic - Non-steroidal anti-inflammatory drugs (NSAIDs) - Administration - Purpose - Effectiveness 2. Opioids - Route of administration - Purpose - Side effects - Effectiveness 3. Regional anesthesia - Assessment - Catheter function - Catheter potency - Neurologic functioning 4. Complementary therapies - Purpose - Effectiveness - Reassessment of therapies 5. Discharge planning - Planning with families - Pain management at home Evaluation 1. Effectiveness of medication 2. Guidelines for medication selection - Dose - Route of administration

IM Injections

Choose the right site - Under 1 Anterior or lateral thigh - Over 1 deltoid and thighs can be used - Appropriate site and needle length depends on age and body mass. - For neonates (first 28 days of life) and preterm infants the anterolateral thigh should be used. A ⅝-inch needle usually is adequate to penetrate the thigh muscle if the skin is stretched flat between the thumb and forefinger and the needle is inserted at a 90-degree angle to the skin.• Choose the right syringe and needle - Amount of medication - IM vs SQ - The anterolateral thigh is preferred for infants younger than age 12 months. For the majority of infants a 1-inch, 22- to 25-gauge needle is sufficient.• 0 For toddlers age 12 months through 2 years the anterolateral thigh muscle is preferred. The needle should be at least 1 inch long. The deltoid muscle can be used if the muscle mass is adequate.• - For children age 3 through 19 years, the deltoid muscle is preferred. The anterolateral thigh also can be used. Needle size for deltoid muscle injections can range from 22 to 25 gauge and from ⅝ to 1 inch depending on the technique used. The anterolateral thigh is the preferred site for IM injection. Never give an IM injection in the buttocks. Ensure needle of appropriate length and gauge is used

CAM (Complimentary and Alternative Medicine) Therapies

Distraction - Help your child learn to focus his attention on something other than pain. Distraction includes activities such as painting, playing board or video games, or watching TV. Visiting with friends or playing with animals may also be a form of distraction. Guided imagery - This teaches your child to put pictures in his mind that will make pain less intense. It may help him learn how to change the way his body senses and responds to pain. Relaxation techniques - Teach your child to breathe in deeply until his stomach rises a bit and then breathe out slowly. To relax his muscles, teach your child to tense up his muscles and then relax them. Guide him through this exercise starting from his foot muscles, slowly going up to his leg, body, arms, and head. Breathing techniques Hypnosis hypno-analgesia is associated with significant reductions in: ratings of pain, need for analgesics or sedation, nausea and vomiting, and length of stay in hospitals. Hypnosis has also been associated with better overall outcome after medical treatment and greater physiological stability. Acupuncture Cutaneous Stimulation

The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

INFANT 0-6 months - Has no understanding of pain; is responsive to parental anxiety - Generalized body movements, chin quivering, facial grimacing, poor feeding - Cries 6-12 months - Has a pain memory; responsive to parental anxiety - Reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritability, restlessness - Cries TODDLER 1-3 years - Lacks understanding of what causes pain and why it might be experienced - Demonstrates fear of painful situations; may resist with entire body or localized withdrawal; aggressive behavior, disturbed sleep - Cries or wails, cannot describe intensity or type of pain - Uses common words for pain such as owie and boo-boo PRESCHOOLER 3-6 years (preoperational) - Pain is a hurt Does not relate pain to illness; may relate pain to an injury - Often believes pain is punishment or someone else is responsible for the pain - Unable to understand why a painful procedure will help them feel better - Active physical resistance, directed aggressive behavior, strikes out physically and verbally when hurt, easily frustrated - Has the language skills to express pain on a sensory level - Can identify location and intensity of pain, may deny pain, may believe their pain is obvious to others SCHOOL- AGED CHILD 7-9 years (concrete operations) - Understands simple relationships between pain and disease - Understands the need for painful procedures to monitor or treat disease - May associate pain with feeling bad or angry - May recognize psychologic pain related to grief and hurt feelings - Passive resistance, clenches fists, holds body rigidly still, suffers emotional withdrawal, engages in plea bargaining - They will stall with logical reason - Can specify location and intensity of pain; can describe physical characteristics of pain in relation to body parts 10-12 years (transitional) - Better understanding of the relationship between an event and pain - Has a more complex awareness of physical and psychologic pain, such as moral dilemmas and mental pain - May pretend comfort to project bravery, may regress with stress and anxiety - Able to describe intensity and location with more characteristics, able to describe psychologic pain ADOLESCENT 13-18 years (formal operations) - Has a capacity for sophisticated and complex understanding of the causes of physical and mental pain - Recognizes that pain has both qualitative and quantitative characteristics - Can relate to the pain experienced by others - Wants to behave in a socially acceptable manner, shows a controlled behavioral response - May immerse self in an activity as a pain distraction - May not complain about pain if given cues that nurses and other healthcare providers believe it should be tolerated - More sophisticated descriptions as experience is gained; may think nurses are in tune with their thoughts, so they do not need to tell the nurse about their pain

Chronic Pain

Persistent Lasting longer than 3 months Generally associated with a prolonged disease process - Such as juvenile idiopathic arthritis or cancer Affects the entire central nervous system - Child has increased neuron responsiveness to painful and non-painful stimuli. Chronic pain may be nociceptive or neuropathic. Behavioral indicators - Fatigue - Inactivity - Posturing - Difficulty concentrating and sleeping - Withdrawal - Mood disturbances Physiologic adaptation Focus on improving function and comfort Cognitive behavioral therapy Physical and occupational therapy Individualized pain management regimen Complementary therapies - Relaxation - Ice - Heat Analgesics - Complete pain relief may not be possible Antidepressants

Opioids

Medications 1. Morphine - IV, IM, SQ, oral - Use for moderate to severe pain 2. Hydromorphone (Dilaudid) oral, IM, IV, rectal - Careful calculation of dose and double-check 3. Levorphanol (Levo-Dromoran) IM, IV, oral - Levorphanol Obtain baseline VS before administering 4. Methadone (Dolophine) Oral, IV - Monitor vital signs and for respiratory depression 5. Fentanyl IV, Intranasal, Transmucosal, transdermal - May be used Q4 hours or continuous infusion

Pediatric Pain Meds

NSAIDS and non opioids for mild to moderate pain 1. Aspirin - Not anymore because of Reye's syndrome under 18. 2. ibuprofen (Advil) 3. naproxen sodium (Aleve) Acetaminophen (tylenol) OPIOIDS for moderate to severe pain 1. Morphine 2. Hydromorphone 3. Fentanyl - More amnesic than pain relief. Co-analgesics for symptoms and side effects 1. Diazepam and midazolam (anti-anxiety) 2. Anti-seizure meds for nerve pain.

Misconceptions About Pain in Children

Newborns and infants do not feel pain, children feel a decreased level of pain as compared to adults - Not true Parents exaggerate or aggravate the child's pain - Not true they are a comfort Children are not in pain if they can be distracted or are sleeping - Not true Children will tell you if they are in pain. They do not need medication unless they ask for it - Not true Children are at greater risk of becoming addicted to pain medications - Not true

Non-Opioid Pain Medication

Non-opioid analgesics - Acetaminophen (Tylenol) given oral, rectal, IV - Use for mild to moderate pain - Ensure that families avoid liver toxicity by using appropriate dosing - Give with food to decrease gastric upset - Give no more than 5 doses in 24 hours Intravenous acetaminophen has a faster onset and results in more predictable pharmacokinetics than oral or rectal acetaminophen What Acetaminophen will not do is reduce inflammation. So, if you have a muscle sprain, or you're suffering from arthritis or any other condition that has inflammation, Acetaminophen may help with the pain, but it will not reduce the inflammation.