Pain Assessment and Management in Children Flashcards
Pain overview
-Significant problem in children –> procedures and disease
-Reported differences in chronic pain prevalence –> gender, age, ethnicity, geographic region
-Pain: prevention, assessment, management
Types of pain
-Acute:
-Recurrent:
-Chronic:
-Mixture:
What does pain do besides hurt?
-Can be harmful –> stress regulation –> hormonal/immune
-Negative consequences –> unrelieved pain
-Poorly controlled pain –> chronic pain syndromes
-Windup phenomenon –> decreased pain threshold and chronic pain
Acute pain presentation
-Certain children more at risk –> preemies
-Needlestick –> procedures as well as immunizations
-Surgical continuum –> nursing assessment –> use of pain scale
-Holistic approach –> CARE approach
Wind-up phenomenon
-AKA central pain syndrome
-Decreased pain threshold and chronic pain
-Progressive increase in spinal cord’s response to repetitive stimulation of peripheral fibers that transmit pain
Chronic pain presentation
-More than 3 months –> can be episodic (eg: headache)
-Enhanced recovery after surgery (ERAS) protocols can be effective –> decreased length of stay, less use of opioids, fewer complications, increased pt satisfaction
Community and home health consideration
-Chronic pain and school absenteeism: comprehensive approach to tx
-Headaches: most common neurologic issue in pediatrics
-Abdominal pain: persistent GI s/s
-Musculoskeletal pain: injury related, illness related or primary pain for more than 3 months
-Neuropathic pain syndromes: dysfunction of somatosensory syndrome (peripheral and central causes), also divided by disease categories
Common mixed-pain conditions in children
-Burn pain: 5th most common nonfatal cause of injury, subtypes –> background, breakthrough, procedural, postoperative
-Cancer pain: symptomatic, result of tx/complications
-Sickle cell pain: hallmark s/s –> severe, acute, episodic, vasooclusive crisis (VOC)
Measuring pain in children
-Use of validated pain scales
-Appropriate for child and level of development
-Assess sleep, emotions, physical fxn, role fxn, satisfaction
-Consistent use of measurement tools
-Observational pain measures –> until child can self-report pain
-Self-reporting pain rating scales –> single more reliable indicator of pain
5 principles of childkind
-An institutional commitment to pain prevention, assessment, and tx
-Ongoing education programs and awareness initiatives on pain for staff, trainees, pts, and any caregivers
-Use of EBP, developmentally appropriate processes for assessment of acute and chronic pain
-Specific evidence informed protocols for pain prevention and tx including pharmacological, psychological, physical methods
-Regular institutional self-monitoring within framework of continuous quality improvement
Goal of pain tx program
-Biobehavioral interventions –> pharmacological and nonpharmacological
-Multimodal pain mgmt
Pain assessment tools
-Behavioral: infants to 4 y
-Physiologic
-Numeric pain ratings: 8+, scale 0-10
-Self-report: not valid for children under 4 y
Influencing factors of pain assessment
-Age
-Developmental level
-Cause and nature of pain
-Ability to express pain
-Core domains: intensity, satisfaction w/ tx, s/s and adverse effects, physical recovery, emotional response, economic factors
Pain assessment components
-Onset
-Duration/pattern
-Effectiveness of current tx
-Factors that aggravate or relieve pain
-Complications and other s/s currently felt
-Interference w/ moo, fxn, interactions w/ family
Assessment of acute pain
-Behavioral: FLACC
-Physiologic: COMFORT, PIPPS, NIPS, CRIES
-Self-reporting: wong-baker, word-graphic, numeric, visual analog, oucher
Behavioral pain assessments
-Assessment of vocalization, facial expression, body mvmts w/ specific tool
-Reliable for short, sharp pain
-Reliable for infant pain
-Not reliable for recurrent or chronic pain
-Not reliable in older children
-FLACC, CHEOPS, TPPR, PPPRS
FLACC
-Components: face, legs, activity, cry, consolability, type of pain
-Score: 0-2 per section
Comfort-B
-Components: pain, stress, distress, sedation
-Acute pain in critically ill, ventilated children
-Assesses for alertness, calmness/agitation, respiratory response or crying, physical mvmt, muscle tone, facial tension, type of pain
Pain rating scales
-Faces
-Oucher
-Poker chip
-Word-graphic rating
-Numeric
-Visual analogue scale (VAS)
FACES pain scale
-AKA wong-baker
-6 cartoon faces
-Smiling face = no pain
-Tearful pain = worst pain
-For children as young as 3 y
Numeric pain scale
-Verbal or may have physical line
-0 = hurt
-5 or 10 = worst pain
-For children as young as 8 y
Chronic and recurrent pain specific assessment
-Chronic: pain for more than 3 months, persists beyond expected period of healing
-Recurrent pain: episodic, recurs, (eg: migraines, sickle cell pain, abdominal pain, limb pain)
Chronic and recurrent pain general assessment
-Multidimensional measures: pediatric pain questionnaire (PPQ), chronic pain –> functional disability inventory (FDI)
-Pain diaries: assess pain s/s and response to tx
-Associated w/ depression and anxiety: children’s depression inventory (CDI)
-Sleep disruption: sleep habits questionnaire
Multidimensional assessments
-Adolescent pediatric pain tool (APPT)
-Assesses pain location, intensity, quality
-Anterior and posterior body outline on 1 side
-100 mm word-graphing rating scale w/ a pain descriptor
-Facilitates assessments of pain quality and location
Pain rating scales for children
Adolescent pediatric pain tool (APPT)
Pain diaries
-Commonly used to assess s/s and response to tx
-Included for children as young as 6 y
-Helps assess anxiety and depression
-Focus on sleep
Pain in neonates
-Response to pain may be behaviorally “blunted” or absent: sleep states in preterm infants, paralytic agents
-CRIES neonatal pain scale: crying, required O2, increased VS, expression, sleeplessness
Premature infant pain profile (PIPP)
-For preemies
-Gives higher pain score to infants w/ lower GA
-Gives higher pain score to blunted behavioral response
Neonatal pain, agitation, and sedation scale (NPASS)
Used in neonates for infants 3-6 m
Young infant’s response to pain
-Generalized response of rigidity and trashing
-Loud crying
-Facial expressions of pain (grimacing
-No understanding of relationship between stimuli and subsequent pain
-Physiologic: changes in HR< RR, BP, O2 sat, sweating, skin color; preemies may have brady, decreased RR, decreased BP and O2 sats
5.4
Older infant’s response to pain
-Withdrawal from painful stimuli
-Loud crying
-Facial grimacing
-Physical resistance to whatever is causing the pain
Toddler/preschooler’s response to pain
-Loud crying and screaming
-Verbalizations: ow, ouch, it hurts
-Thrashing limbs
-Attempts to push away stimulus
-Needs physical restraints usually
-Begs for procedure to end
-Need for hugs
-Fear when anticipating procedure
School-age child’s response to pain
-Stalling behavior: wait a min, I’m not ready
-Muscle rigidity
-May use all behaviors of a young child
Adolescent’s response to pain
-Less vocal protest; less motor activity
-Increased muscle tension and body control
-More verbalizations: it hurts, you’re hurting me
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
Children w/ chronic illness and complex pain
-Difficult to isolate pain s/s from other s/s
-Rating pain does not always accurately convey to others how they really feel
Cultural barriers to pain tx
-Inadequate assessment of pain
-Concern of side effects and tolerance of analgesics
-Fear that pain may worsen disease
-Reluctance to report pain
-Reluctance to take pain meds
-Lack of adherence to tx plan
Barriers to pain mgmt
-Family issues/relationships
-Fear of addiction
-Lack of knowledge
-Inappropriate use of pain meds
-Ineffective mgmt of adverse effects from meds
Goals of pain mgmt
-Atraumatic care
-Reduction of pain
-Reduce anxiety
-Decrease need to use physical restraints
-Avoid long lasting consequences of poor pain mgmt
Biobehavioral strategies for pain mgmt
-General: establish trust, express concern, take active role, prepare, stay, educate
-Specific: distraction, relaxation, guided imagery, positive self-talk, thought stopping, behavioral contracting
Nonpharmacologic pain interventions
-For children: distraction, relaxation, guided imagery, cutaneous stimulation
-For infants: containment, positioning, nonnutritive sucking, kangaroo holding
Nonpharmacologic pain mgmt
Buzzy bee: uses distraction, cold, and buzzing vibrations to physiologically block pain by competing for the brain’s attention
Complementary and alternative medicine (CAM)
-Biologically based: foods, special diets, herbs, vitamins
-Manipulative tx: chiropractic, osteopathy, massage
-Energy based: reiki, magnetic tx, pulsed fields
-Mind body techniques: mental or spiritual healing, hypnosis, relaxation
-Alternative medical systems: homeopathy, traditional Chinese medicine
Pharmacologic mgmt
-2 step strategy: NSAIDS for mild pain, opioid (morphine) for moderate/severe pain
-Dosing at regular intervals
-Using appropriate route of administration
-Adapting tx to the individual child
-Older than 3 m: 1st administer non-opioid analgesic (acetaminophen and NSAIDS), start opioids when pain is severe or unrelieved by nonopioids (morphine drug of choice)
Eval of medicine effectiveness
-15 min after IV route
-30 min after IM route
-30-60 min after oral route
Nonopioids and opioids
-Nonopioids for mild to moderate pain: acetaminophen, NSAIDS
-Opioids for moderate to severe pain: morphine, codeine, fentanyl
-Morphine (gold standard): drug of choice for PCA, 1 mg/mL
-Other opioids: hydromorphone, meperidine, oxycodone (w/ or w/o acetaminophen)
Side effects of opioids
-Respiratory depression
-Constipation
-Pruritus
-N/V
-Sedation
-Tolerance
-Physical dependence
Managing opioid-induced respiratory depression
-Assess sedation level: if sedated –> stimulate
-Monitor for pain/progressive sedation and respiratory depression
-Not aroused or apneic: stop or reduce opioid, administer O2 and support respirations, initiate resuscitation efforts as appropriate, administer naloxone (narcan)
Adjuvant drugs
-Used alone or with opioids to control pain symptoms and opioid side effects
-To enhance analgesics, not substitute for analgesics
-Anxiolytics, sedatives, amnesics: Diazepam (Valium) and midazolam (Versed)
-Tricyclic antidepressants and antiepileptics for neuropathic pain
-Stool softeners & laxatives for constipation
-Antiemetics for nausea & vomiting
-Diphenhydramine for itching
-Steroids for inflammation and bone pain
-Dextroamphetamine and caffeine for possible increased pain & sedation
Choose the timing/method of analgesia
-Continuous pain control: around the clock (ATC), achieves a steady state
-Routes of admin: know onset, peak effect, duration; know drug metabolism, consider extended relief
PCA mechanism of action
-Log, programmed, verified
-3 modes: pt admin –> bolus preset dose and lockout interval, nurse admin –> initial loading dose and relive breakthrough pain, continuous infusion –> delivers constant analgesic amt
Epidural anesthesia
-Common meds: fentanyl, hydromorphone, preservative-free morphine
-Opioids combined w/ local anesthetic (bupivacaine or ropivacaine)
-Instilled via single or intermittent bolus, continuous infusion, or patient-controlled epidural analgesia (PCEA)
Epidural nursing care
-Prevent opioid-induced respiratory depression: careful monitoring of sedation level, careful monitoring for respiratory depression
-Skin care around catheter insertion site
-Assessment pain
