8. Pain Management for Children Flashcards
What is Pain?
Pain is whatever the person experiencing the pain says it is; existing wherever the person says it does
Obstacles to Pain Management in Children
* Myths
* Knowledge deficits
* Inaccurate pain assessment
* Insufficient awareness of pain management interventions
* Lack of confidence; lack of communication
* Personal attitudes and beliefs about pain:
> Fear of respiratory depression and fear of addiction
Assessment of Pain in Children
* Multidimensional and subjective
* Type and duration of pain
* Developmental level and emotional status
* Previous experience with pain
> Some cultures expect child to “be brave”
* Culture and ethnicity
* Personality type
* Gender
* Genetic variations
* Parental response to child’s pain
Assessment of Pain According to Developmental Levels
Neonate & Infants
* Facial expressions (frowns, grimaces, wrinkled brow; expression of surprise, and facial flinching)
* BP and HR may increase but oxygen saturation may decrease
* High-pitched, tense, harsh crying
* Generalized or total body response to pain
* Thrash extremities and exhibit tremors
* Older infants may localize pain…rubbing area, pull away and guard the involved part
Toddler
* Loud crying
* May use words like “ouch” “hurt” “boo-boo” to indicate pain
* May attempt to delay procedure if perceived painful
* Generalized restlessness
* Guard site
* Touch painful areas
* May run from nurse
Preschooler
* Thinks pain is punishment for something said or done
* Cry and struggles
* Describes location and intensity “my ear hurts a lot”
* Regression to earlier behaviors…loss of bladder and bowel control
* Withdrawn
* May deny pain to avoid medication (injection)
* May have been told to “be brave” and deny pain
School-Age Children
* Describes pain and quantify intensity
* Fears bodily injury
* Awareness of death
* Stiff body posture
* Withdrawn
* Procrastinates or bargains to delay procedure
Adolescent
* Perceives pain at physical, emotional, and cognitive level
* Understands cause and effect
* Describes pain and quantify intensity
* Increased muscle tension
* Withdrawal and decreased motor activity
* Words like “sore” “ache” or “pounding”
Assessment Tools
- Use a tool that is appropriate for the child’s developmental level
* Adolescent and Pediatric Pain Tool (APPT)
* CRIES Pain Scale
* COMFORT Behavior Scale
* Face, Legs, Activity, Cry, Consolability (FLACC)
* FACES Pain Rating Scale
* Oucher Pain Scale
* Poker Chip Tool
* Visual Analog Scale (VAS)
* Numeric Rating Scale (NRS)
Children older than 3 (preschoolers and school-age) - use self-reporting tools like FACES, Oucher, Poker Chip
Adolescent and Pediatric Pain Tool (APPT)
* 3-part tool - body outline…intensity scale…pain descriptor list
* Ages 8-17 years
CRIES Pain Scale
* 5 behavioral categories
- Crying
- Requiring O2 for SaO2 <95%
- Increased vital signs
- Expression
- Sleeplessness
* High score indicates pain
* Neonates and 0-6 months
COMFORT Behavior Scale
* 6 categories
- Alertness
- Calmness/agitation
- Respiratory response (if on ventilator) or crying (if breathing spontaneously)
- Physical movement
- Muscle tone
- Facial tension
* Higher score indicates pain/distress
* Infants and children in critical care
Face, Legs, Activity, Cry, Consolability (FLACC)
* Use with preverbal or nonverbal child and cognitively impaired child
* Based on cues
* Five categories
FACES Pain Rating Scale
* 6 cartoon pictures ranging from happy face to crying face
* 3 years old and older
Oucher Pain Scale
* Culturally sensitive assessment
* Ethnic and gender specific
* 3-12 years old
* 0-100 point scale
Poker Chip Tool
* Four poker chips are used to represent “a piece of hurt”
* 4-12 years old
Visual Analog Scale (VAS)
* 10-cm line
* One end “no pain” while other end “worst pain”
* 7-18 years old
Numeric Rating Scale (NRS)
* Number reflects pain level; 0 = no pain; 1-3 = pain; 4-6 = moderate, 7-10 = severe
* Age 9 and older
Non-Pharmacological Interventions
Parents play a crucial role assisting the nurse in assessing and managing the child’s pain
* Assess for information on what interventions have worked in the past
Distraction
* Most used
* Must be developmentally appropriate
* Playing with toys
* Video games / blowing bubbles
* Videos/music; singing; reading
Regulated breathing
* Simple mode for biofeedback
* Teach slow, rhythmic breathing
Guided imagery
* Encourage child to remember or image sounds, sights, and smells of an enjoyable item or experience
Biofeedback
* Measurement of physiological indicators like BP, HR, temperature, sweating, and muscle tension
* Alerts for early signs of tension so as to initiate relaxation techniques
Progressive muscle relaxation
* Involves relaxation of muscle groups
* Hypnosis, acupuncture
* Topical heating, cooling
* Massage
* TENS (transcutaneous electrical nerve stimulation)
> Small amounts of electrical energy that interfere with transmission of pain signals
* Techniques for neonates and infants
> Non-invasive techniques used during and/or painful procedure or experience
* Includes breastfeeding; sucking on a pacifier; skin-to-skin contact (kangaroo care) directly on mother’s chest; holding and rocking; swaddling
Pharmacological Interventions
Administration of analgesics
* Patient-controlled analgesia
> Most effective to administer opioids
> Patient controls infusion of bolus
> Disadvantage if patient is sedated or sleeping won’t administer the bolus
> Two RN’s must check bag or syringe
> Once pump is programmed two RN’s must check the programmed pump
> Assessment for over-sedation
> And IV naloxone (reversal med), oxygen, and bag-valve mask always available
> Pain assessment every 1-4 hours
* Topical anesthetic agents
> Lidocaine-prilocaine 5% cream (EMLA); numbing skin for invasive procedures
Acetaminophen and anti-inflammatory drugs
* Acetaminophen (brand name Tylenol) most commonly used
* Safe in neonates
* No gastric irritation or GI bleeding side effects
* NSAIDs reduce fever, pain, and inflammation
* Treatment of choice for moderate pain related to bone injuries or cancer
* Ibuprofen, Aleve, Naprosyn, Toradol
* Aspirin should be avoided in children because of Reye Syndrome
Acetaminophen
Classification: analgesic/antipyretic
Action: unknown
Indications: mild to moderate pain or fever
Dosages & Routes: Not to exceed 4000 mg/day
Adverse Reactions: rash
Nursing Considerations: Can be crushed. Chewable tablets should be thoroughly chewed and wet before swallowing.
Ibuprofen
Classification: NSAID, analgesic
Action: Blocks prostaglandin synthesis
Indications: relief of mild to moderate pain in children >6 months of age; chronic, symptomatic RA and OA
Dosages & Routes: Maximum daily dose 2400 mg
Adverse Reactions: heartburn, nausea, vomiting, epigastric or abdominal discomfort or pain, GI ulceration
Nursing Considerations: Give with meals or milk to decrease GI intolerance.
Opioids
* Moderate to severe acute and chronic pain; postoperative; post-traumatic; cancer pain
* Fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone
* Adverse effects: sedation, respiratory depression, constipation, pruritis, N/V, cough suppression, urinary retention
Hydrocodone
Classification: opioid analgesic
Action: binds to opiate receptors in the CNS to diminish pain
Indications: mild pain to moderate pain; acute pain
Dosages & Routes: PO 0.1-0.15 mg/kg every 3-4 hours
Adverse Reactions: N/V, constipation, pruritis, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, and dependance
Nursing Considerations: Nausea is a common side effect, report if accompanied by vomiting.
Oxycodone
Classification: opioid analgesic
Action: inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception
Indications: moderate to severe pain; acute or chronic pain
Dosages & Routes: PO starting dose, 0.1-0.2 mg/kg/dose every 4-6 hours
Adverse Reactions: N/V, constipation, pruritis, dizziness, lightheadedness, confusion, hallucinations, mood changes, sedation, respiratory depression, and dependance
Nursing Considerations: Nausea is a common side effect, report if accompanied by vomiting. Titrate dose up or down to maximize pain relief and minimize adverse effects.
Morphine
Classification: opioid analgesic
Action: binds with CNS opiate receptors, alters physical and emotional response to pain
Indications: moderate to severe pain; acute and chronic pain
Dosages & Routes: maximum dose - 15 mg/dose
Adverse Reactions: primarily CNS sx’s such as dizziness, lightheadedness, drowsiness, sedation, lethargy, euphoria, restlessness, respiratory depression. N/V, constipation; urinary retention; pruritis
Nursing Considerations: Nausea is a common side effect, report if accompanied by vomiting. Monitor I&O. Begin with lowest dosage and titrate dose up or down to maximize pain relief and minimize adverse effects.
Procedural Sedation
* Medically controlled state of depressed consciousness
* Maintain oxygenation and airway control and are able to respond to verbal and tactile stimulation
* Minimum, moderate (conscious sedation), and deep
Epidural Anesthesia
* Inserted into epidural space
* Used in abdominal, GU, open-heart, thoracic, and orthopedic (lower limbs) surgeries
> Continuous cardiac monitoring and pulse oximeter
Pain Management in Children
* Preferred routes are IV or oral
* As soon as the child can tolerate oral intake, the route should be changed
* Rectal is avoided as could be disturbing to child
* IM is avoided because of the fear of “shots”
* Infants and children receiving IV and epidural opioids should be monitored by pulse oximetry and cardiac monitor
* Risk for respiratory depression is greatest during the first 24 hours
* If respiratory depression occurs with opioid use, naloxone hydrochloride should be used for reversal when oxygen and stimulation of the child are ineffective
