Chapter 05 - Pain Assessment and Management in Children Flashcards
The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route?
a.
Less expensive than oral medications
b.
Produces a first-pass effect through the liver
c.
Does not need to be administered frequently
d.
Provides most rapid onset of effect, usually in about 5 minutes
ANS: D
The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.
Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group?
a.
“No hurt.”
b.
“Red pain.”
c.
“Zero hurt.”
d.
“Least pain.”
ANS: A
“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. “Least pain” is less concrete than “no hurt.”
A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which?
a.
Give only an opioid analgesic at this time.
b.
Increase dosage of analgesic until the child is adequately sedated.
c.
Plan a preventive schedule of pain medication around the clock.
d.
Give the child a clock and explain when she or he can have pain medications.
ANS: C
For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child’s attention on how long he or she will need to wait for pain relief.
Which coanalgesics should the nurse expect to be prescribed for pruritus? (Select all that apply.)
a.
Naloxone (Narcan)
b.
Inapsine (Droperidol)
c.
Hydroxyzine (Atarax)
d.
Promethazine (Phenergan)
e.
Diphenhydramine (Benadryl)
ANS: A, C, E
The coanalgesics prescribed for pruritus include naloxone, hydroxyzine, and diphenhydramine. Inapsine and promethazine are administered as antiemetics.
A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
a.
The child will continue to sleep and be pain free.
b.
Parents cannot administer additional medication with the button.
c.
The pump can deliver baseline and bolus dosages.
d.
There is a high risk of overdose, so monitoring is done every 15 minutes.
ANS: C
The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.
The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching?
a.
“With minimal sedation, the patient’s respiratory efforts are affected, and cognitive function is not impaired.”
b.
“With general anesthesia, the patient’s airway cannot be maintained, but cardiovascular function is maintained.”
c.
“During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation.”
d.
“During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation.”
ANS: D
When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.
A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety?
a.
Lorazepam (Ativan)
b.
Gabapentin (Neurontin)
c.
Hydromorphone (Dilaudid)
d.
Morphine sulfate (MS Contin)
ANS: B
Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.
Which are components of the FLACC scale? (Select all that apply.)
a.
Color
b.
Capillary refill time
c.
Leg position
d.
Facial expression
e.
Activity
ANS: C, D, E
Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC scale.
The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on which characteristic about preterm infants’ pain?
a.
They may react to painful stimuli but are unable to remember the pain experience.
b.
They perceive and react to pain in much the same manner as children and adults.
c.
They do not have the cortical and subcortical centers that are needed for pain perception.
d.
They lack neurochemical systems associated with pain transmission and modulation.
ANS: B
Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.
What is a significant common side effect that occurs with opioid administration?
a.
Euphoria
b.
Diuresis
c.
Constipation
d.
Allergic reactions
ANS: C
Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.
Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?
a.
Codeine sulfate (Codeine)
b.
Morphine (Roxanol)
c.
Methadone (Dolophine)
d.
Meperidine (Demerol)
ANS: B
The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.
Which is a complication that can occur after abdominal surgery if pain is not managed?
a.
Atelectasis
b.
Hypoglycemia
c.
Decrease in heart rate
d.
Increase in cardiac output
ANS: A
Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. Hypoglycemia, decreases in heart rate, and increases in cardiac output are not complications of poor pain management.
A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which?
a.
Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
b.
Use a combination of fentanyl and midazolam for conscious sedation.
c.
Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
d.
Apply a transdermal fentanyl (Duragesic) “patch” immediately before the procedure.
ANS: B
A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.
The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.)
a.
Color
b.
Moro reflex
c.
Oxygen saturation
d.
Posture of arms and legs
e.
Sleeplessness
f.
Facial expression
ANS: C, E, F
Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.
What describes nonpharmacologic techniques for pain management?
a.
They may reduce pain perception.
b.
They usually take too long to implement.
c.
They make pharmacologic strategies unnecessary.
d.
They trick children into believing they do not have pain.
ANS: A
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.
