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Pain Assessment and Management in Children Flashcards

1
Q

Pain overview

A

-Significant problem in children –> procedures and disease
-Reported differences in chronic pain prevalence –> gender, age, ethnicity, geographic region
-Pain: prevention, assessment, management

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2
Q

Types of pain

A

-Acute:
-Recurrent:
-Chronic:
-Mixture:

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3
Q

What does pain do besides hurt?

A

-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

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4
Q

Acute pain presentation

A

-Certain children more at risk –> preemies
-Needlestick –> procedures as well as immunizations
-Surgical continuum –> nursing assessment –> use of pain scale
-Holistic approach –> CARE approach

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4
Q

Wind-up phenomenon

A

-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

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5
Q

Chronic pain presentation

A

-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

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6
Q

Community and home health consideration

A

-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

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7
Q

Common mixed-pain conditions in children

A

-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)

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8
Q

Measuring pain in children

A

-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

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9
Q

5 principles of childkind

A

-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

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10
Q

Goal of pain tx program

A

-Biobehavioral interventions –> pharmacological and nonpharmacological
-Multimodal pain mgmt

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11
Q

Pain assessment tools

A

-Behavioral: infants to 4 y
-Physiologic
-Numeric pain ratings: 8+, scale 0-10
-Self-report: not valid for children under 4 y

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12
Q

Influencing factors of pain assessment

A

-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

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13
Q

Pain assessment components

A

-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

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14
Q

Assessment of acute pain

A

-Behavioral: FLACC
-Physiologic: COMFORT, PIPPS, NIPS, CRIES
-Self-reporting: wong-baker, word-graphic, numeric, visual analog, oucher

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15
Q

Behavioral pain assessments

A

-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

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16
Q

FLACC

A

-Components: face, legs, activity, cry, consolability, type of pain
-Score: 0-2 per section

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17
Q

Comfort-B

A

-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

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18
Q

Pain rating scales

A

-Faces
-Oucher
-Poker chip
-Word-graphic rating
-Numeric
-Visual analogue scale (VAS)

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19
Q

FACES pain scale

A

-AKA wong-baker
-6 cartoon faces
-Smiling face = no pain
-Tearful pain = worst pain
-For children as young as 3 y

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20
Q

Numeric pain scale

A

-Verbal or may have physical line
-0 = hurt
-5 or 10 = worst pain
-For children as young as 8 y

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21
Q

Chronic and recurrent pain specific assessment

A

-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)

22
Q

Chronic and recurrent pain general assessment

A

-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

23
Q

Multidimensional assessments

A

-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

24
Pain rating scales for children
Adolescent pediatric pain tool (APPT)
25
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
26
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
27
Premature infant pain profile (PIPP)
-For preemies -Gives higher pain score to infants w/ lower GA -Gives higher pain score to blunted behavioral response
28
Neonatal pain, agitation, and sedation scale (NPASS)
Used in neonates for infants 3-6 m
29
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
30
Older infant's response to pain
-Withdrawal from painful stimuli -Loud crying -Facial grimacing -Physical resistance to whatever is causing the pain
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
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
39
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
40
Nonpharmacologic pain interventions
-For children: distraction, relaxation, guided imagery, cutaneous stimulation -For infants: containment, positioning, nonnutritive sucking, kangaroo holding
41
Nonpharmacologic pain mgmt
Buzzy bee: uses distraction, cold, and buzzing vibrations to physiologically block pain by competing for the brain's attention
42
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
43
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)
44
Eval of medicine effectiveness
-15 min after IV route -30 min after IM route -30-60 min after oral route
45
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)
46
Side effects of opioids
-Respiratory depression -Constipation -Pruritus -N/V -Sedation -Tolerance -Physical dependence
47
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)
48
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
49
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
50
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
51
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)
52
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

Pediatrics (24 decks)

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