Pediatric Pain Assessment

You are caring for a 10 month old 20lb infant who is POD #0 following a right ureteric reimplantation procedure. You assess that the child is having severe pain. You know from the parents that their infant has never had opioid pain medications before. You have an order for Morphine 1.2mg IV Q3hr PRN severe pain. This dose is safe: True False

(6-12 mo=100-200 mcg/kg, p.129) 0.9-1.8 mg -need to check

When can children start using the FACES pain scale?

-3 yo

What is pain?

-A personal phenomena that cannot be experienced by any other individual -whatever the person experiencing it says it is -verbal expressions -non-verbal expressions

When assessing a child who complains of abdominal pain, what is the MOST appropriate nursing action? -Palpate the most painful area first, to get it over with -Palpate around the tenderness -Avoid painful areas until the end of the assessment -Perform deep painful palpation for abdominal tenderness

-Avoid painful areas until the end of the assessment

A child who is one (1) day post-op following an appendectomy refuses to get up and walk, has increased blood pressure and heart rate. What is the BEST nursing intervention? -Tell the child that walking will help with pain control -Check the MAR to see when the last pain medication was given and administer the pain medication -The goal is to wean the patient off addicting narcotics -Give the child a developmentally toy/game in order to distract the child from thinking about the pain

-Check the MAR to see when the last pain medication was given and administer the pain medication

The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the nurse that she does not have pain, but a few minutes later she tells her parents that she does. Which should the nurse consider when interpreting this? -Truthful reporting of pain should occur by this age -Inconsistency in pain reporting suggests that pain is not present -Children use pain experiences to manipulate their parents -Children may be experiencing pain even though they deny it to the nurse

-Children may be experiencing pain even though they deny it to the nurse

Techniques for non-pharaceutical pain relief in preschoolers

-Distraction devices (toys, games, books, videos, stories) -Guided imagery -Play therapy -Hugging, holding -Massage -positioning

Techniques for non-pharaceutical pain relief in toddlers

-Distraction devices (toys, music, videos) -Security object (blanket, toy, stuffed animal) -Pacifier -Touch, massage -Hugging, holding, positioning -Imagery, play -Heat, cold

What is the gold standard for infant response to pain?

-FACIAL expression -eyes forcibly closed -lowered brows, drawn together -deepened furrow between nose and outer corner of lip -square mouth -cupped tongue -cheeks raised -nose broadened and bulging

True or false: infants don't feel pain

-FALSE -Infants demonstrate behavioral, especially facial and physiologic, including hormonal indicators of pain. Neonates have the neural mechanisms to transmit noxious stimuli by 20 weeks of gestation.

The nurse is caring for a 12-year-old Cerebral Palsy patient who is unable to communicate verbally or by pointing. Which of the following pain assessment tools is the most appropriate? -A pain diary that the family records -FLACC scale -Numeric rating scale -FACES scale

-FLACC

True or false: children become accustomed to pain or painful procedures?

-False -Children exposed to repeated painful procedures often experience increasing anxiety and perception of pain with repeated procedures. -PTSD -NICU graduates and pain experiences

True or false: children always tell the truth about pain.

-False -Children may not report pain due to fear of administration of a painful injection or fear of lengthening their hospital stay. Children with chronic pain may not be fully aware they are experiencing pain. Children may be developmentally unable to communicate their pain, or parents may not think it necessary to tell health professionals about the pain.

True or false: children tolerate pain better than adults

-False -younger children experience higher levels of pain during procedures than older children -children's tolerance for pain increases with age

Techniques for non-pharaceutical pain relief in school aged kiddos

-Heat / cold application -Touch / massage -Play therapy -Guided Imagery -Humor -Distraction -Positioning -Hugging, holding

Opioids analgesics (meds and side effects)

-Hydrocodone (+Tylenol)- Lortab, Norco, Vicodin -Morphine -Fentanyl -Oxycodone -Hydromorphone (Dilaudid) Opioid side effects include: nausea, vomiting, constipation, and pruritus

Techniques for non-pharaceutical pain relief in adolescents

-Imagery -Heat / cold application -Relaxation techniques -Humor -Breathing techniques -Prayers -Distraction

How to assess pain on school aged and adolescents

-Increased ability to communicate pain in more abstract terms -They can describe pain; squeezing, stabbing, or burning -Responds well to direct questioning -Tools: body outline, FACES scale, visual analog

What are the physiologic effects of acute pain?

-Increased heart rate -Increased respiratory rate -Increased blood pressure -Decrease in oxygen saturation

What are the metabolic effects of acute pain?

-Increased secretion of catecholamine, glucagon, and corticosteroids -Delayed wound healing -Poor intake / anorexia -Impaired mobility -Sleep disturbances -Irritability

What are the route of med administration and how fast do they work?

-PO - preferred if possible / slower pain relief -Topical - pain free / slower pain relief -IM - not preferred, involves a needle each time -IV - rapid pain relief, easy route with an established IV access

Techniques for non-pharaceutical pain relief in infants

-Positioning -Swaddling -Rocking / cuddling -Touch / massage -Dim lighting -Visual distraction -Sucking, sucrose/water solution on pacifier

True or false: narcotics are more dangerous for children than they are for adults?

-Respiratory depression is one of the most serious side effects of opioids but it is a rare occurrence with children. In children older than 3 months of age, opioids cause no greater respiratory depression than in adults. -Respiratory depression is more likely to occur in conjunction with the administration of drugs such as midazolam or diazepam.

What questions can the nurse ask the child when in pain?

-Tell me what pain is -Tell me about the hurt you have had before -What do you do when you hurt? -Do you tell others when you hurt? -What do you want others to do for you when you hurt? -What does not help? -What helps the most to take away the hurt?

What is addiction?

-a persistent pattern of dysfunctional opioid use that may involve any or all of the following: -Adverse consequences associated with the use of opioids -Loss of control of the use of opioids -Preoccupation with obtaining opioids, despite the presence of adequate analgesia

What is pseudo-addiction?

-clock watching -not to be confused with using opioids for reasons other than pain control -drug seeking

What should be considered when assessing the effects of pain medication on a child?

-consider patient's normal routines -is it nap time?

The use of placebos can be an effective strategy for an adolescent who you suspect is having some drug-seeking behaviors True False

-false

True or false: children cannot tell you where they are hurt

-false

True or false: children's behavior reflects their pain intensity?

-false -Children are unique in their coping styles. Behavior alone is not a reliable indicator of pain level

True or false: children can become easily addicted to narcotics

-false -Less than 1% of children treated with opioids develop addiction -one of the reasons for unfounded and prevalent fear is confusion among terms of: dependence, tolerance, and addiction

What is the FLACC pain assessment scale used for? How does it work?

-infants and preverbal or non-verbal kiddos -FACE (0-2, no expression to clenched jaw) -LEGS (relaxed, to tense to kicking) -ACTIVITY (quietly lying to squirming, to rigid and jerking) -CRY (no cry to moan or whimper to steady cry and scream) -CONSOLABILITY (relaxed to reassured by touching to difficult to console)

What are some pharmacological interventions for pain?

-mild pain: acetaminophen, and NSAIDS -moderate to severe: opioids, non-opioids, local or topical anesthetics -persistent moderate to severe pain: continuous around the clock dosing at fixed intervals is recommended -PCA: used only when the patient can use the pump on their own (around 6-7 years old)

operative pain

-morbidity and mortality can be reduced by good pain management -plans for post-op pain discussed before surgery -goal is to control pain as rapidly as possible

Surgery has informed a nurse that the patient returning to the floor after spinal surgery has an opioid epidural catheter for pain management. The nurse should prepare to monitor the patient for which side effects of an opioid epidural catheter? (Select all that apply.) -Urinary frequency -Nausea -Pruritis -Respiratory depression

-nausea

what symptom is often present with pain?

-nausea, treat both

What are some patient barriers to pain relief?

-negative attitudes toward taking medicines -fear of injections -fear of addiction to narcotics -patients may be labeled as complainers

What kind of non-pharaceutical interventions do you use for each age group?

-neonate/infant: sensory -toddler: sensory -Preschooler: sensory/behavioral -school age/adolescent: sensory/behavioral/ cognitive

What is the 5th vital sign?

-pain -do it overtime you take vitals -pain is sensory and emotional -use PEW scoring

What needs to be documented about pain?

-pain intensity -quality -appropriate to patients age -recorded in a way that facilitates reassessment and follow up

What is the single most reliable indicator of pain?

-patient self report

Why does under treatment of pain occur?

-professional misconceptions about pain -complexity of pain assessment especially in non-verbal patients -Lack of information on current pain reduction techniques -the biggest cause is failure to assess adequately and differences between clinicians and patients perceptions of pain

Pre-procedural pain (how to lower anxiety and prepare)

-related pain is anticipation -anticipated intensity and duration -child/parent receive appropriate information to minimize stress -quiet environment -calm nurse -pain management -local anesthetics, systemic agents, and sedatives -Parents are encouraged to be present - the team will need to determine if this is beneficial -Child Life Specialist - pre-procedural preparation and support during procedures -Painful procedures should be done in the treatment room

What should be monitored with use of narcotics?

-respiratory status

How do you assess pain for a toddler or preschooler?

-they are limited in their cognitive abilities in localizing and expressing pain intensity, and understanding reasons for pain -find out words they use to express pain -point to pain -FACES is a good tool for over 3 yo

How to assess pain in children with cognitive impairment

-vocal behavior: crying, moaning, and screaming -social behavior: withdrawn, difficult to distract, not cooperative -facial expression: clenches or grinds teeth, thrusts tongue out, furrowed brow -activity: not moving, stiff, tense, agitated -physical signs: change in color, perspiring, gasping

Do children often require more pain medication than adults?

-yes by mg/kg -dont under medicate!

When can children start using a numeric scale?

7 yo

Local anesthetics

EMLA Elamax Lidocaine

You are caring for a 2-year-old child who has recently returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain? -FACES -FLACC -N-PASS -Numeric scale 1-10

FLACC

What are some non-opioid analgesics

Non-opioid analgesics: -Acetaminophen -Ibuprofen -Ketorolac

Physiologic measurements in children's pain assessment are: -The best indicator of pain in children of all ages -Essential to determine whether a child is telling the truth about pain -Of most value when children also report having pain -Of limited value as sole indicator of pain

Of limited value as sole indicator of pain

What are some questions about pain that the nurse can ask the parents?

Questions for the parents: -Describe any pain your child has had before -How does your child usually react to pain? -How do you know your child is in pain? -What do you do to ease discomfort for your child? -What does your child do to get relief when hurting? -What works the best to decrease or take away the pain?

What is physical dependence?

a physiologic state in which abrupt cessation of the opioid results in a withdrawal syndrome. Physical dependence is an expected occurrence in the presence of continuous use of opioids for therapeutic or nontherapeutic purposes, it does not, in and of itself imply addiction. -ITS EXPECTED AND A PHYSICAL STATE

At what age can children accurately point to the body area in pain or mark the painful site on a drawing?

age 4

What makes pain multifactorial?

it can be: -sensory -affective -behavioral -cognitive -sociocultural -physiological

Non pharmacologic strategies for pain management... -may reduce pain perception -make pharmacologic strategies unnecessary -usually take too long to implement -trick children into believing they do not have pain

may reduce pain perception

What is the N-PASS scale used for?

neonates

What is tolerance?

neuroadaptation to the effects of chronically administered opioids that is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. Tolerance can occur both to the analgesic and the unwanted side effects of the drugs. The occurrence of tolerance is variable but does not in and of itself imply addiction.

True or false: Titrate pain medication in increments when possible

true

Can patient discomfort be caused by things other than pain?

yeah

Do infants experience pain?

yes

If a child is lying still, could they still be in pain?

yes