Pain Assessment In Neonates Infants And Children Flashcards
Pain
Is whatever the experiencing person says it is , existing when he says it does
Always believe the pt
True or false neonates do not feel pain with teh same intensity as adults because a child nervous system is immature
False
Nociception
The process by which pain becomes conscious
Ex premature infant demonstrates severe stress response to painful stimuli
Why is it important to relief pain in and infants?
It can permanently change their nervous system and may prime them for having chronic pain
T or f
Repeated experience w pain teaches the chid to be more tolerant of pain and cope with it better
False
Does a chid or an adult tolerate pain better?
An adult does.
A children’s tolerance to pain actually increases with age.
Do children get accustomed to painful procedures?
Negative ghost rider
Children often demonstrate increased behavioral signs of discomfort with repeated painful procedures
Ex of a chid demonstrating increased behavioral response to pain with a repeated procedure
A chid with a chronic illness an hospitalized frequently. After repeated lumbar spine the child becomes more resistant each time
Why wouldn’t a child tell you that they are hurt
Nonverbal
To avoid injections
Constant/chronic pain
They believe others know how they feel
Culture(pain seen as weakness)
Gender (boys wont admit)
What are ways a nonverbal kid can tel you they are in pain
Pointing at the site of where it hurts or using appropriate pain scale
Why would It look like a child is not in pain
Developmental level
The way they cope
Temperament
Activity level
Intensity of reaction to pain
Physical dependence
Withdrawal symptoms when chronic use of an opioid is discontinued or an opioid antagonist (naloxone or narcan) is give
It may require gradually reducing the dose over several days
Withdrawal
A collection of symptoms both behavioral and physiologic that occurs when opiates or sedatives that have been administered for seven days or more are abruptly decreased or discontinued
Manifestations of withdrawal :behavioral
Anxiety, agitation, insomnia, tremors
CNS symptoms of withdrawal
Irritability
GI dysfunction of withdrawal
N&V diarrhea or feeding intolerance
Autonomic dysfunction of withdrawal
Tachypnea tachycardia fever sweating and hypertension
Drug tolerance
Need for larger dose of opioid to maintain original effect or more frequent doses
May occur when children have been taking opioids or sedatives for several days (5-7)
What can a child’s tolerance increase other than the drug
The side effects like respiration depression
Sedation
Nausea
Narcotic addiction behavioral and voluntary
Compulsive drug seek behavior
Not for medical reasons like pain relief
Best way to assess pain
Self report and if they can score it on a pain scale
Nonspecific ways nonverbal vocalize pain
Cry scream groan
2nd best indicator of pain
Behavioral
Facial expression
Posture
Activity
Behavioral state
Response to intervention
Behavioral state
Sleep wake cycle. Are they sleeping more than usual?
Third way to assess pain
Physiologic
Vital signs o2
Hormonal changes
Sweating
Palmar (sweating)
Last way to assess pain
Pain stimuli /history (sickle cell always in pain)
Temperament
Age,sex
Culture
Significant other input
QUESTT
Question the pt
Use pain rating scale
Evaluate behavior and physiologic signs
Secure family’s involvement
Take cause of pain into acct
Take action and assess effectiveness
Verbal indications of pain
May speak “i dont feel good”
May deny pain due to fear of injections
Use a variety of words boo boo or Owie, ouch
Other languages “ay ay”
Question parents
How can we have child locate pain
Marking body parts on human figure drawing
Point the area with one finger on self doll stuffed animal
Three categories of pain intensity scales each measuring different parameters
Subjective
Behavioral
Multidimensional
Subjective
Asking pt to score for you
Behavioral
Based on pt behavior
Multidimensional
Typically the scales that are used in the nicu
Measuring more than one thing
Subjective pain scales
Wong baker faces
Ouches scale
Word graphic scale
Numeric rating scale
Wong baker faces pain rating scale
6 drawn faces
Continuum from smiling to tearful
For children as young as 3
Explain how to use
And do not compare child’s face with those on the pain scale
Oucher pain scale
Six photographs of child’s face from no hurt to biggest hurt you could ever have
Difference races
Children 3-13
Word graphic rating scale
Use descriptive words to denote varying intensities of pain
Explain each word no pain to worst possible pain
Starting at age 4 to 17
Numeric scale
In order to utilize the numeric pain scale they must be able to count an have a number concept and under stand concepts
More or less
Higher or lower
Number order
“What is bigger 5 or 8”
What ages is numeric scale used
Age 5 and older but really when they have an understanding the numeric scales can be at around 7-8
Behavioral pain scales
Flacc
Revised flacc
Modified flacc
FLACC
Face legs activity cry consolability
May be used for 2 mo to 7 yr
Observe 1 to 5 min during routine care
Add scores from 5 categories for total score
Great for infants up to 3 years
Flacc “face “ 0 1 2
0 No particular expression or smile
1 occasional grimace or frown withdraw disinterest
2 frequent to constant quivering chin , clenched jaw
Legs flacc 0 1 2
0 normal position or relaxed
1 uneasy restless tense
2 frequent to constant quivering chin, clenched jaw
Activity flacc 0 1 2
0 lying quietly normal position moves easy
1 squirming shifting back and forth , tense
2 arched, rigid or jerking
Cry flacc 0 1 2
0 no cry (awake or asleep )
1 moans or whimpers, occasionally complaint
2 crying steadily screams or sobs frequent complaint
Consalibility flacc 0 1 2
0 content relaxed
1 reassured by occasional touching, hugging, talk to , distractable
2 difficult to console or comfort
Revised flacc
For children with cognitive impairment
Modified flacc scale
Mechanically ventilated pt
Multidimensional rating scales
N-pass
Nips
Pipp
Cries
NPASS
23-40 wk gestation
Combines assessment of pain agitation and sedation
For procedural and prolonged pain
NIPS neonatal infant pain scale
Children less than 1 226-40 wk gestation
Composed of 6 indicators and each behavioral indicator is score w 0 1 except for cry which is 0,1,2
Observed for 1 min
PIPP
0 - 6 indicates minimal or no pain
7-12 indicates slight to moderate pain
Greater than 12 indicates severe pain
Total score 0-21
25-40 weeks (hesi says 28-40)
For procedural and post op pain
Cries
10 pint scale
Used for neonates greater than or equal to 32-40wks of gestation (32-60 wks)
For post op pain
Consist of 5 physiologic and behavioral indicators which are rated on a 3 point scale
Signs of pain in infants and children vocalized
Crying often w apneic spells
Whimpering groaning moaning
State changes possible signs of pain in infants and children
Chang in sleep wake cycle
Changes in activity level
Agitation or listlessness
Bodily movement signs of pain in infants and children
Limb withdrawal , swiping or thrashing
Rigidity
Flaccidity
Clenching of fist
Facial expression signs of pain in infants
Most reliable signs
Eyes tightly closed or opened
Mouth opened , squarish
Furrowing or bulging of brow
Quivering of chin and tongue
Deepened nasolabial fold
Infant -pain
Loud inconsolable crying
Facial expression of pain
Decreased appetite
Infant pain
Loud inconsolable crying
Facial expression of pain
Decreased apetitie
young children pain
Kind crying or screaming
Using words such as ouch or it hurts
Thrashing of extremities
Clinging to parent
Restless and irritable
Lack of cooperation
School age child
Stalling
Muscular rigidity
Restlessness
Sleep disturbances
Adolescent pain
Withdrawn
Decreased activity
Increased muscle tension
Behaviors that indicate location of pain
Pulling ears
Rolling head side to side
King on side w legs flexed on abdomen
Limping
Refusing to move a body part
Physiological pain in neonatal
Increase HR RR BP
Shallow respirations
Vagal nerve tone (shrill cry)
Pallor or flushing
Diaphoreses palmar swearing
O2 sat
Increased muscle tone
EEG changes
Indications of acute pain physiological fight or flight
Dilated pupils
Increased perspiration
Increase rate force of hr
Increased rate / depth of resp
Increase bp
Decreased urine output
Decreased peristalsis of gi tract
Increased bMR
Do we prioritize physiologic for pain
Negative ghost rider it should be used adjuncts to self report
Acute pain
Activates body’s fight or flight stress response
Chronic pain
When pain persist body begins to adapt and there is a decrease in the sympathetic responses
Stress response is absent or diminished
What is the only reason to assess pain
To take action to relief it
Iv analgesics
Assess after 5- 15 min
Po analgesics
30-60 min
