Care of the Hospitalized Child and Pain Flashcards
Pain Assessment: Influencing Factors
age
developmental level
cause and nature of the pain
ability to express the pain
Types of Pain
acute
chronic
recurrent
Chronic Pain
- pain that persists for 3 months or more
- pain that persist beyond expected period of healing
Recurrent Pain
episodic
recurs
ex) migraines, sickle cell pain, recurrent abdominal pain, limb pain
Pain Assessment: Components
- onset of pain
- pain duration/pattern
- is current tx effective?
- factors that aggravate or relieve the pain
- other symptoms and complications concurrently felt
- interference w/ the child’s mood, function, and interactions with family
Pain Assessment Tools
behavioral:
- infants to age 4
physiologic
self report:
-not valid for children younger than 4
Behavioral Pain Assessments
- assessment of vocalization, facial expression, and body movements w/ specific tool
- most reliable for short, sharp pain and in infants
- less reliable for recurrent or chronic pain and in older children (may not correlate w/ child’s self-report of pain)
Behavioral Pain Assessment Tools
- FLACC
- FACES Pain Scales
- Numeric Pain Ratings
- Premature Infant Pain Profile (PIPP)
- Neonatal Pain, Agitation, and Sedation Scale (NPASS)
- Oucher Pain Scale
FLACC
Face Legs Activity Cry Consolability
0-2 score for each
FACES Pain Scales
Wong-Baker FACES Pain Scale
-six cartoon faces
- smiling face = no pain
- tearful face = worst pain
child chooses a face that describes his/her pain
widely used in US
Numeric Pain Ratings
0-10 scale widely used
easy to use
for 8 years and older
little research for reliability and validity
Premature Infant Pain Profile (PIPP)
- specifically developed for premature infants
- gives higher pain score to infants w/ lower gestation age
- gives higher pain score to blunted behavior response
Neonatal Pain, Agitation, and Sedation Scale (NPASS)
used in neonates from 23 weeks of gestation up to 100 days of age
Measuring Pain in Children w/ Communication and Cognitive Impairment
difficult to measure pain
high risk for inadequate tx of pain
NCCPC: non-communicating children’s pain checklist
PICIC: pain indicator for communicatively impaired children
Oucher Pain Scale
- for 3-12 year olds
- validated w/ african-american and caucasian children
- hispanic version of APTT scale available for children/adolescents w/ cancer
uses body outline diagram of the APPT for non-english speaking children and adolescents
Cultural Barriers to Pain Tx
- inadequate assessment of pain
- concern about side effects and tolerance of analgesics
- fear that pain means worse disease
- reluctance to report pain
- reluctance to take pain meds
- lack of adherence to tx plan
Children w/ Chronic Illness and Complex Pain
- difficult to isolate pain symptom from other symptoms
- rating pain does not always accurately convey to others how they really feel
Barriers to Pain Management
- family issues and relationships
- fears and concerns about addictions
- lack of knowledge about pain
- inappropriate use of pain meds
- ineffective management of adverse effects from meds
Nonpharmacologic Pain Interventions
- distraction
- relaxation
- guided imagery
- cutaneous stimulation
- heat or ice pack for older children
Nonpharmacologic Pain Interventions for Infants
- containment
- positioning
- “non nutritive” sucking
- kangaroo holding
- sucrose
ComplementaryAnd Alternative Medicine (CAM)
diverse practice which is grouped into 5 classes:
- biologically based: foods, special diets, herbal, vitamins
- manipulative treatments: chiropractic, osteopathy, massage
- energy based: reiki, magnetic treatment, pulsed fields
- alternative medical systems: homeopathy, traditional Chinese medicine
Pharmacologic Management
- non-opioids for mild to moderate pain (acetaminophen, NSAIDs)
- opioids for moderate to severe pain (morphine, codeine, hydromorphone, fentanyl)
SE of Opiods
- respiratory depression
- constipation
- pruritus
- n/v
- sedation
- tolerance
- physical dependence
Tolerance
- dose must be increased to achieve the same effect
- may develop after 10-21 days
- Tx: increase dose, decrease duration between doses
Evaluation of Effectiveness of Pharmacologic and Nonpharmacologic Interventions
- evaluate q15-30min after intervention
- document findings
- ongoing assessment
Consequences of Unrelieved Pain in Neonates
physiologic changes:
- increased ICP, HR, RR, BP
- decreased SaO2
behavioral changes:
- muscle rigidity
- facial expression
- crying
- withdrawal
- sleeplessness
Normal Stressors for Children
- potty training
- puberty
- starting school
- birth of sibling
- loss of a loved object
- loss of a loved one
Patient and Family Centered Care (PFCC)
- family is the child’s primary source of strength and support
- hospitalization alters the parental role
- nurses are role models and mentors for engaging parents in hospital in hospital routines and daily care that benefits the child
Why are children particularly vulnerable to illness and hospitalization?
- illness and hospitalization constitute a major life crisis
- stress represents change from the usual routine
- usual coping mechanisms are inadequate to solve the problem
How children respond to illness and hospitalization depends on:
- child’s coping abilities
- temperament
- past experiences
- family support
Major stressors for infants/children/adolescents when hospitalized:
- Separation
- Loss of Control
- Bodily injury
Infancy: Stage and Age
Trust vs Mistrust (0-1YO)
Separation
Separation in Infants
- pre-attachment: major reaction to illness and hospitalization are pain, immobilization, and change in normal routine
- young infants react w/ crying, fussiness, decreased sleep, and loss of appetite
-attachment: by end of 4-6 months, major reaction occurs as a result of separation, should be avoided
Toddler: Stage and Age
Time of Autonomy
12 months - 2 years
Toddler: Causes of Main Reaction to Stress
- Separation
- Loss of Control
- Bodily Injury
Separation in Toddlers
separation anxiety
- Protest: cries loudly, screams for mom/dad/caretaker, refuses attention from anyone else, inconsolable grief, acutely distressed
- Despair: crying stops, increasing hopelessness, less active, disinterested in toys or play or food, withdraws. Child looks lonely, isolated, depressed, child may regress.
- Detachment: superficially the child has adjusted to loss, becomes more interested in surroundings, plays w/ others, seems to form attachments, but when parent coms in - ignores parent, does not acknowledge, will not greet, keeps on playing
Nursing Care During Separation Stages in Toddlers
protest: don’t leave alone, reassure
despair: spend time with, talk about family, don’t leave alone, TLC
detachment: help parents understand this stage, they need to give lots of TLC
* toddlers after separation may regress when parent returns
Loss of Control in Toddlers
- any restriction on newly acquired skills is a threat to sense or security
- any alteration in routines and rituals
- unfamiliar environment (new sounds, smells)
- end result = regression, increased fear, fussiness, restlessness, change in sleep patterns, refusing to eat
Bodily Injury and Pain in Toddlers
- intrusive procedures are very anxiety producing
- toddlers react to painless procedures just as intensely as painful procedures
- toddlers remember painful procedures (Elamax Cream)
- if toddlers c/o pain, take it seriously
Preschool: Stage and Age
initiative stage
pre-operational
magical thinking
3-5 YO
Separation in Preschool Age
can tolerate brief periods of separation from parents
- are able to develop substitute trust in other significant adults
- protest behaviors are often more subtle and passive (may withdraw, refuse to eat, cry silently, express anger through throwing toys and refusing to do self care activities)
Loss of Control in Preschool Age
caused by:
- physical restriction
- altered routines
- enforced dependency
cognitive level and magical thinking makes them feel out of control
- fantasize that hospitalization may be a punishment
- need reassurance that it is not their fault
Bodily Injury and Pain in Preschool Age
- body integrity poorly defined so intrusive procedures (whether painful or painless) are threatening
- reacts to painful procedures much like toddlers
- painless procedures are more tolerated
- preschoolers may benefit from preparation before painful procedures
Reaction to Pain in Preschool Age
- aggression: push person away or lock themselves in a safe place
- verbal response: “go away” or “I hate you”
- dependency: clinging to parent
they need support, so let them act out
Mutilation in Preschool Age
this is a huge fear at this age
loss of body part is very threatening
limited comprehension of body functioning and increases difficulty understanding how or why body parts are fixed
School Age: Stage and Age
Industry
Concrete Operational
Past/Present/Future Time Oriented
6-13 YO
Separation in School Age
- better able to cope w/ separation, but need parental presence
- middle and late school age children may react more to separation from their usual activities and friends than absence of parent
- loneliness and boredom, depression
Loss of Control in School Age
- striving for independence and productivity
- lessens their feeling of control and power
- lack of privacy
give them back control:
-helping to choose schedule, assist w/ procedures, choose what to wear, choose their menu
Bodily Injury and Pain in School Age
- less concern w/ pain than w/ disability, uncertain recovery and death
- know death is final
- major fear is being told something is wrong with them
- they take active interest in their health or illness
- education works well w/ this age group
- They want answers, so deal w/ injury and pain w/ factual information
- Intrusive procedures are well tolerated, concerns for privacy
- may deal w/ painful procedure by participating in the procedure
- give some control “which arm would you like your shot in”
Indirect Request for Support or Help in School Age
nonverbal cues:
- half hearted “I’m fine”
- lack of activity
- social isolation
Adolescence: Stage and Age
identity
formal operation
over 13 YO
Main threats in Adolescence
- Loss of control - especially in terms of identity
- Fear of altered body image
- Separation - primarily from members of their support group
Separation in Adolescence
- loss of peer group contact may be great emotional threat
- teens greatly benefit from other teens while in the hospital
- may welcome separation from parents
Loss of Control in Adolescence
- illness and hospitalization separates them from peers
- lack of physical activity
- pt role fosters dependence and depersonalization
- due to these items, teens may reject care, be uncooperative, withdraw, show anger/frustration, be aggressive
Bodily Injury and Pain in Adolescence
- biggest stressor for teens = fear of being different from one’s peers
- reaction to pain is generally much more controlled and physical resistance and aggression are unusual at this time
Nursing Interventions to Minimize the Stressors of Illness and Hospitalization
- realize the stressors of each age period
- accept the behavioral reactions
- provide support and assistance needed for successful coping
- teach parents about developmental needs, reactions to illness and hospitalizations
How to Prevent or Minimize Separation
- primary nursing
- encourage parents to participate in the planning and carrying out of the child’s care
- provide options about participation, may need a rest or break
- assess the situation and provide support
- help families determine how to best meet the needs of the whole family
- picture of family
- recording of family voices reading or telling stories
- help parents separate (no sneaking out)
- help parents explain separation and when they will be back
- encourage frequent parental visits
- explain to parents how the child acted after separation
- create familiar surroundings
- help children maintain usual contacts and routines
- talk to children about their feelings
- encourage playroom
How to Minimize Loss of Control
- increase mobilization by carriage, stroller, wagon, wheelchair
- maintain consistent and normalized daily schedule/routine
- encourage choice in schedule
- keep busy
- encourage independence and self care (wear street clothes)
- provide developmentally appropriate activities
How to Decrease Bodily Injury and Pain
- prepare children for procedures (simple honest explanations)
- 3YO+ use dolls, pictures, verbal and demonstrate
- very young children: perform procedures as quick as possible, maintaining parent/child contact, distraction does very little, anticipatory teaching only often increases fears
- give permission to express pain
- use band-aid
- assess pain and take measures to relieve pain
- play to decrease anxiety and increase coping
- use tx room for painful or invasive procedures
- divisional activities
Following Hospitalization
under 4YO, will demonstration effects of hospitalization including:
- aloofness
- increased fears
- oppose any separation
- new fears
- nightmares
- regression
- enuresis
- withdrawal and shyness
- temper tantrums
- anger at parents
may last days to 1 month
Parent Reaction when a child is hospitalized
- guilt
- ashamed
- left out
- self pity
- grief
- anxiety
- resentment
- fear of replacement
- helplessness
Sibling Response to Hospitalized Child
- behavior changes: loneliness, fears, anger, resentment, jealousy, guilt
- parents need to know that siblings are affected
- siblings need to know that their feelings are common
- siblings need to be incorporated in the plan of care, teaching plan
Care of Infants, Children, and Adolescents during Pre-Op Period
children need to be prepared psychologically
help deal w/ common fears:
- under 4: separation
- 4-7: punishment and mutilation
- 8-13: reality and death
- teens: being different
What to Teach Pre-Op and Post-Op
pre-op: NPO, procedures, meds
post-op: NG, catheter, IV, PCA, ambulation, IS, C&DB
Timeframe for teaching about surgery
- older child and teen: 1 week before
- 4-7: 1-2 days before
- 3-4: 1 day before
- 2 and under: morning of or just before
always include parents in teaching
NPO in Peds
- after midnight: no food, milk, milk products or non-clear juice
- breastfed: up to 4 hours before
- clear fluids: until 2 hours before
- push fluids the night before
During Surgery
- anesthesia: rapid RR maintained
- blood loss of 10% can lead to shock
- fluid balance: infants dehydrate quickly, strict I&O’s
Causes of Temp Increase
- infection
- excess blankets/coverings
- warm room
- malignant hyperthermia
Causes of Increased HR
- increased temp
- pain
- shock
- meds
Causes of Decreased BP
- shock
- opioids
- vasodilating meds
Causes of Increased RR
- increased temp
- pain
- increased fluid volume
- respiratory distress
Causes of Temp Decrease
- cool room
- muscle relaxants
- infusion of cool fluids
- sepsis (infants)
- shock
Causes of Decreased HR
- hypoxia
- increased ICP
- meds
Causes of Increased BP
- increased ICP
- pain
- meds
- increased fluid volume
Causes of Decreased RR
- opioids
- anesthetics
Post-op Care to Reduce the Risk of Infection
- diaper below incision line (if abdominal)
- reinforce dressing until changed by surgery for the first time
- frequent VS
- assess for unusual drainage, discharge
Post-Op
IV hydration and feeding:
- NPO until awake and alert
- start w/ sips and chips
- strick I&Os
- weight is best judge of I&O
- prevent complications
- ambulate early
- discharge instructions
