Pain Assessments Flashcards
Newborns and young infant response to pain
crying
brows lowered and drawn together
tightly closed eyes
mouth open
squarish
rigid, thrash, withdrawal reflex
no relationship btw causing pain and response
Older infant response to pain
crying
deliberate withdrawal from cause
pain and anger expression
physical struggle, esp. pushing away
Young child response to pain
crying and screaming
“Ow, Ouch, It hurts”
thrash around
push when pressure applied
lack of cooperation (possible need for restraint)
begs for end
clings to family, nurse
requests physical comfort
restless and irritable
worries for anticipation of actual procedure
School-age response to pain
includes all young children’s responses +
behaviors during the procedure not before
Time wasting “Wait a Minute or I’m not ready”
Muscular rigidity (fist clenching, white knuckles, teeth grit, contracted limbs, stiffness, closed eyes, wrinkled forehead)
Adolescent response to pain
less vocal with less restraint
More verbal in the expression “You’re hurting me”
Increased muscle tone and body control
Manifestations of Pain in the Neonate
VS
increased heart rate, BP,
rapid, shallow respirations
decreased O2 Sat
Manifestations of Pain in the Neonate
Physical
pale or flushed
sweating
increased muscle tone
dilated pupils
low vagal nerve tone
Increased ICP
low pH, high glucose, and corticosteroids
Manifestations of Pain in the Neonate
Behavioral responses
crying
whimpering
groaning
grimace, quiver, tightly closed eyes
mouth open and squarish
limb withdrawal
thrash, rigid, flaccid
fist clenching
Manifestations of Pain in the Neonate
Changes in sleep, nutrition, or activity
fussiness, irritability
listlessness
inability to sleep at times
Nonpharmacologic Strategies for Pain Mgmt
child-life specialist - doll medical play
trusting relationship
express concern regarding their pain and intervention efficiency
active role in seeking effective strategies
preparation for the procedure with atraumatic care
prepare before pain BUT avoid planting the idea of pain - parents to stay if desired
- use non pain descriptors
Instead of saying “This is going to (or may) hurt” what should you say to the child?
“Sometimes this feels like pushing, sticking, or pinching, and sometimes it doesn’t bother people. Tell me what it feels like to you.”
Types of Distraction Techniques
audio or visual deterrents
deep breaths and blowing
bubbles
Kaleidoscopes
Use humor
with friends
Types of Relaxation Techniques
comfort positions
rock wide and rhythmically (NOT bouncing)
repeat comfort phrases “Mommy’s here”
If older = deep breaths, limp like a rag doll, exhale, then yawn, progressive staring with toes, keep eyes open
Types of Guided Imagery Techniques
Happy Places
describe details
write down script
encourage to go to a pleasurable place
combine with breathing and relaxation
Types of + self-talk Techniques
positive statements
Types of Stop Thoughts Techniques
+facts
reassuring
brief statements and memorize them
Types of Behavioral Contracting Techniques
And age
4-5 y/o
rewards
limit the time of procedure to the child
reinforce cooperation with a reward if accomplished within a specific time
Contract (formal) - goals and desired behavior, measurable behaviors, written, dated, and signed, rewards and consequences, evaluate, and commitment
Managing Opioid Side Effects
Constipation
constipation: stool softeners, increase intake (prune juice, bran cereal, veggies) and exercise
Managing Opioid Side Effects
Sedation
Sedation: caffeine
if persists seek alternative
Managing Opioid Side Effects
N/V
ondansetron, imagery, deep and slow breathing
Managing Opioid Side Effects
Pruitus
Naloxone, oatmeal baths, good hygiene,
exclude other causes of itching
change opioid
Managing Opioid Side Effects
Respiratory depression (mild-moderate-severe)
Mild to moderate: arouse gently, O2, encourage deep breaths, hold dose and reduce dose to 25%
Severe: O2, bag and mask when indicated, Naloxone, opioid switch
Managing Opioid Side Effects
Dysphoria, confusion, hallucinations
rule out other causes
Haldol or opioid switch
Managing Opioid Side Effects
Urinary retention
eliminate antihistamines, antidepressants
Oxybutynin
In/out or indwelling cath
If respirations are depressed (opioid-induced)
assess sedation
reduce infusion by 25 % if possible
stimulate pt
admin O2
If pt can’t be aroused / apneic from preparation oioid induced depression, then
initiate resuscitation
Naloxone (Narcan) bolus by slow IV push every 2 minutes until effect
close monitor pt (duration is shorter than opioid requiring repeated doses)
For children < 40 kg (88lbs) dilute 0.1 mg naloxone in
10 mL sterile saline to make 10 mcg/mL solution and give 0.5 mcg/kg
For children > 40 kg (88lbs) dilute 0.4 mg naloxone in
10 mL sterile saline and give 0.5mL
Signs of opioid tolerance
decreased pain relief and duration of relief
Initial Signs of Withdrawal Syndrome in Patients with Physical Dependence
Lacrimation
Rhinorrhea
yawning and sweating
Later Signs of Withdrawal Syndrome in Patients with Physical Dependence
restlessness
irritable
tremors
anorexia
dilated pupils
goosebumps
N/V
Physical dependence
abrupt cessation of the opioid, or administration of an opioid antagonist, results in a withdrawal syndrome.
does not imply addiction
Tolerance
neuroadaptation to the effects of chronically administered opioids after 10-21 days of morphine
need for increasing or more frequent doses of the medication to achieve the initial effects of the drug.
does not imply addiction
Addiction
persistent pattern of dysfunctional opioid use:
adverse consequences, loss of control, preop with obtaining opioids
Consequences of Untreated Pain in Infants
pain triggers constant stress responses
- hemorrhage, high morbidity, hypersensitive, unknown origins of pain, poor motor functions, neuro and cognitive behaviors, inabile to cope, impulsivity, learning deficits,
emotional temperament in childhood
Define Pain for a pt
whatever the experiencing person says it is, existing whenever he says it does
BELIEVE THE PT
True meaning of pain in medical terms
unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
T/F: Neonates and Infants Do Not Feel Pain With The Same Intensity As Adults Because A Child’s Nervous System Is Immature.
False, pain is felt regardless of age
Actually feel more pain due to immature nervous system and lack of gate
The youngest premature infant has the anatomic and physiologic components to perceive ___________ and demonstrates what?
nociception
The complete myelination of nerve pathways is not required for
pain transmission
Nociception
Process by which pain becomes conscious
Transduction
process of noxious stimuli converted to electrical signals (impulses) in sensory nerve endings
Transduction occurs at the site of
tissue damage
What is the process of pain perception
Transduction
Transmission
Perception
Modulation
Transmission of pain
spreading the sensation along the nerves to the CNS (ending in the brain stem)
Perception of pain occurs
transmission reaches the brain and is perceived as a conscious, emotional and physical experience
Modulation involves
changing or inhibiting the transmission of the initial impulse
- occurs after the perception of pain reaches the brain
Premature infants may have a
greater sensitivity
Why do infants have a greater sensitivity to pain?
can not control the gate of the Nervous system as well so they feel more pain
Unrelieved pain in infants can permanently change their nervous system and may
prime them for having chronic pain
T/F: Repeated Experience With Pain Teaches The Child To Be More Tolerant Of Pain And Cope With It Better.
False, children do not tolerate pain better than adults.
Children’s tolerance to pain actually __________ with age.
increases
- some they have more pain
Children do not become accustomed to pain/painful procedures; they actually demonstrate an
increased behavioral signs of discomfort with repeated painful procedures
Children have increased behavioral signs of discomfort because
they know what it feels like
T/F: Children usually don’t tell you if they are in pain.
True, some children won’t tell you if they are in pain to be brave or have cultural tendencies.
T/F: Children do not need medication unless they appear to be in pain.
False, children can tell you where they hurt and accurately point to the area or draw beyond infancy
If a child is nonverbal, how will they express their pain?
pointing or drawing a picture of the painful sites
show on the pain scale at 3+
Children do/do not always admit to having pain.
do not
Why would a child not admit to having pain?
avoid injections
constant/chronic pain (normal is a 2-3 to others)
believe others know how they are feeling (egocentricity)
culture seen as a weakness, stoic or expressive when expressing emotions)
gender (suck it up and be a man)
Behavioral manifestations of pain may not reflect pain
intensity
Predominantly crying and difficult mood
Pain s/s may be affected by
developmental level
coping abilities
temperament (activity level, intensity of reaction, influence pain behavior)
If the child has a decreased activity level and a decreased intensity of reaction, it may make it more
difficult to realize they are in pain
A child with an increased intensity of reaction and negative mood may look like
they are in a lot of pain
What are some behavioral traits that would make it more difficult to see if they are hurting?
decreased activity level
increased adaptability
decreased intensity of the reaction
positive or neutral mood
T/F: Infants And Children Have No Memory Of Pain.
False, infants cry in anticipation of immunizations
- associate alcohol smell with heel sticks and will pull their feet away to avoid the pain
T/F: Parents Exaggerate Or Aggravate Their Child’s Pain
False, parents know their children better than anyone else and able to identify when the child is in pain
T/F: Parents want to be involved in their child’s pain control.
TRUE, parents need info about assessing pain and using interventions to relieve pain
Parental presence during painful procedures is
desirable for the child and parent
What can a nurse teach the parents regarding pain interventions?
nonpharmacologic measures lessen the child’s pain
parental presence during procedures (Atraumatic care)
T/F: Children Often Become Addicted To Pain Medication.
FALSE, physical dependence if on 7 + days and need to wean off or develop tolerance
One reason for the prevalent fear of addiction from opioids used to relieve pain is a misunderstanding of
differences between drug tolerance, addiction, and physical dependence
Physical dependence
withdrawal symptoms when chronic use of an opioid is D/C, or an opioid antagonist (Naloxone or Narcan) is given
Physical dependence may require reducing the dose of opioids
gradually (weaning off over several days without symptoms)
Opioid antagonist
Narcan or naloxone
Physical dependence develops when the pt is on opioids for how long
typically 7+ days
Withdrawal
collections of symptoms (behaviors and physiologic) occur when opioids or sedatives have been administered for 7 days +
and abruptly decreased or D/C
Withdrawal s/s
anxiety, agitation, insomnia, and tremors
irritable
N/V/D or feeding intolerance
HIGH HR, RR, BP, and fever
sweating
Involuntary physiologic responses relates to what drug effect
Drug tolerance
Drug tolerance
need a larger dose to maintain original effect (or more frequent)
Drug tolerance could occur when children have been taking opioids or sedatives for
several days (5-7)
Tolerance side effects
respiratory depression
sedation
nausea
Stop after initial doses
When do the side effects of opioids usually occur?
initial dose and improves after 2 days
Narcotic Addiction is what type of pattern
behavioral and voluntary
Narcotic Addiction is characterized by
compulsive drug-seeking behavior
Narcotic Addiction leads to
overwhelming involvement with acquiring the drug
Narcotic Addiction is the use of opioid
NOT for medical reasons (pain relief)
Addiction r/t pain tx with opioids characterized by
a persistent pattern of dysfunctional opioid use
- impaired over drug use
- compulsive drug use
- continued use of drugs despite harm
Addiction r/t pain tx with opioids involves
adverse consequences
loss of control
preoccupation with obtaining opioids despite adequate analgesia
What factors characterize the complex condition of addiction with opioids
genetic, psychosocial, and environmental
The continued use of the drug causes changes in the _______ ________ leading to
brain wiring
leads to powerful cravings and difficulty stopping the drug
Infants, young children, and comatose or terminally ill children _________ become addicted because they are incapable of a consistent pattern of drug-seeking behavior
can not
T/F: Children Are Not In Pain If They Can Be Distracted Or They Are Sleeping.
False, distraction to cope
Children use what to cope with pain
distraction
Children use distractions to cope with pain, but soon they become
exhausted when coping with pain from energy spent up and fall asleep
An infant may be experiencing pain even when
lying quiet with eyes closed
Is this infant experiencing pain?
If they are postoperative, they may wake and complain of pain and then fall back to sleep because of the anesthesia.
Yes
QUEEST is what type of assessment
Multidimensional Model of Pain Assessment mnemonic
QUEEST
QU = vocal
E = behavioral
E = Physiologic
ST = contextual
What is the gold standard for pain assessment?
patient self-report (vocal)
Vocal assessment of pain includes what in multidimensional
Specific = self-report
Nonspecific = cry, scream, groan
Nonspecific vocal assessment
cry
scream
groan
Behavioral assessment in multidimensional
Facial expressions
rigid posture
less activity
sleep more
response to interventions
Contextual assessment in multidimensional
pain stimulus/ hx
temperament
age, sex
culture
significant other input
Physiologic assessment in multidimensional
VS
O2 change
hormonal changes
sweating
palmar sweat
QUESTT assessment
Question the pt and parents
Use pain rating scale
Evaluate behavior and physiologic signs
Secure family’s involvement
Take cause of pain into account
Take action and assess the effectiveness
Verbal Indications of Pain
less common than adults
not understand the pain term
speak globally “I don’t feel good.”
Deny pain for fear of injection
Cries, screams, groans, moans
Synonyms for pain in children
hurt
owwie
ow ow
booboo
ouch
don’t feel good
What do you call pain at home?
Synonyms for pain in other languages
ay ay
duele
lele
dolor
When questioning the parents about pain what should be said?
previous experiences with pain
Initial Pain Assessment
Location (point/drawing)
Quality
Intensity
Onset, duration, variation, and patterns
Alleviating and aggravating factors
maybe not all from pt but some helps
How can a child show the nurse the location of the pain?
marking body parts on a human figure drawing
point to an area on self, doll, or stuffed animal
Transition objects
When selecting a scale that is appropriate for a child what should the nurse take into account?
age
developmental level and abilities
When should you teach a child to use the pain scale?
before pain is expected (preoperative)
however not always the case
Use the _______ scale with a child each time pain is assessed
same
What should you tell/present to a physician regarding a pt’s pain to lead to a favorable change in analgesic orders?
objective documentation
rather than opinions
If a physician only ordered acetaminophen with hydrocodone po for a postoperative patient and you administer it for a pain level of 8, and after 30-60 minutes, they are still hurting at a 6. What would you tell the physician?
pain scale would be beneficial in getting additional opioid orders to better alleviate the child’s pain
When should you reassess pain?
30-60 minutes after giving medication
What are the 3 pain intensity scales?
Subjective
Behavioral
Multidimensional
Subjective pain scales
scores and 1-10s
Wong-Baker FACES Pain Scale
Oucher Scale - vertical with races of pain
Word-Graphic Scale - only words an line
Numeric Rating Scale = 1-10
Behavioral pain scale
assessing behaviors identified as indicators of pain
- FLACC
- Revised FLACC
- Modified FLACC
Multidimensional pain scale
NICU - undergone reliability and validity testing
-N-PASS
-NIPS
-PIPP
-CRIES
Wong-Baker FACES Pain Rating Scale
- subjective
- 6 drawn faces from smiling to tears
Wong-Baker FACES Pain Rating Scale
is used on what age of children?
3+ years old
T/F: You can not compare the child’s face with those on the FACES Wong-Baker scale.
True, the faces could be subjective to the person based on the culture
- You don’t have to cry to have the worse pain/hurt.
The Oucher pain rating scale uses
6 photographs of a child’s face from “no hurt” to “biggest hurt you could ever have”
Oucher pain rating scale includes
vertical sale of Caucasian, AA and Hispanic children
The Oucher pain scale is for children
3-13 years old
Word-Graphic Rating Scale uses
descriptive words with vary intensities of pain
With the word-graphic rating scale, the nurse needs to explain
each of the words to the child
from “no pain”
to “worst possible pain”
The Word-graphic rating scale is used in children’s ages
4-17 years old
In order to utilize the numeric pain scale, what age do they need to be and they must be able to
5+ (school age more like 6-8)
count and have a number concept and understand concepts
- More or less
- Higher or lower
- Number order
According to The Children’s Hospital Association, the numeric rating scales is appropriate for a child who is at least
developmentally 7-8-year-olds
FLACC stands for
Face
Legs
Activity
Cry
Consolablilty
FLACC is used on children’s ages
2 months to 7 years
FLACC behavior needs to be observed for how long
1-5 minutes during routine care
The FLACC total score is calculated by
adding up all 5 categories
Pre-verbal is for
infants to 3+
A high FLACC score is
high pain
A low FLACC score means
little to no visible pain
The revised FLACC scale is used for all children with
cognitive impairment
The revised FLACC score shows the
behaviors commonly associated with pain in cognitively impaired children
- caregiver to identify pain behaviors specific to child assessed
The modified FLACC Scale is used in children with
mechanically ventilated pts
The modified FLACC scale includes
additional parameters for cry category assessment
Which is the most appropriate pain scale for procedural pain in the intubated child?
Modified FLACC Scale
N-PASS stands for
Neonatal Pain, Agitation, and Sedation Scale
NPASS is used in what specific department
NICU
N-PASS is used in what “age” of children
23-40 weeks gestation
N-PASS combines
assessment of pain
agitation
sedation
N-PASS is used in
preemies with procedural and prolonged pain
The N-PASS looks like what in adults
MEWS score but for neonates with assessment criteria reared towards premature pain
What are the assessment criteria for the N-PASS?
crying, irritability
behavior state
facial expression
extremities tone
VS (HR, RR, BP, and O2)
What are the best (no pain) to worst (worst pain or sedation) scores on the NPASS?
Sedation -25 = -10
Normal = 0 (best)
Pain/Agitation = 25= 10
Assessment Sedation criteria for -2 on NPASS
no cry with painful stimuli
no arousal to any stimuli
no spontaneous mvmt
mouth is lax
no expression
no grasp reflex
flaccid tone
no VS variable with stimuli
Hypoventilation or apnea
Assessment Pain/Agitation criteria for -2 on NPASS
high pitched or silent-continuous cry
Inconsolable
arching, kicking, constantly awake
arouses minimally/no mvmt (not sedation)
any pain expression continual
continual clenched toes, fists, and finger splay
tense
> 20% from baseline
< 75% with stimulation (slow increase)
out of sync with vent
Assessment Normal criteria for 0 on NPASS
appropriate crying
not irritable
appropriate behavior for gestational age
relaxed appropriate
relaxed hands and feet
normal tone
within baseline or normal for them
NIPS stands for
Neonatal Infant Pain Scale
NIPS is recommended for children
less than 1 year old (26-40 weeks)
NIPS is composed of how many indicators
6
In the NIPS scale, each behavioral indicator is scored from
0 or 1 with 0,1,2 for crying
NIPS scale is observing the neonate for
1 minute
The NIPS scale best with no pain score is
0 (calm, sleep, absent)
The NIPS scale with worse pain score is
7 (contracted, vigorous/mumbling crying, different breathing, flexed, uncomfort)
NIPS score is based on
facial expression
cry
breathing
arms
legs
alertness
PIPP scores
minimal or no pain
0-6
PIPP scores
slight to moderate pain
7-12
PIPP scores
severe pain
12+
The max severe score for PIPP is
21
PIPP is used for
procedural and post-op pain
PIPP is used for what age of children?
25-40 weeks (HESI 28-40)
CRIES is what type of scale
10 points
CRIES is used for
neonates 32-40 weeks gestation
- 32-60 weeks for HESI
CRIES is used for
postop pain
CRIES consists of
5 physiologic and behavioral indicators rated from 0-2
On the CRIES scale, if the score is 3+, what does the nurse do?
some intervention should be initiated
On the CRIES scale, if the score is 4+, what does the nurse do?
indicates the infant should be medicated
The CRIES scale cannot be utilized on infants who are
intubated
paralyzed
bc they can not grimace or cry
In the CRIES scale the higher the score the
higher intervention needed
Behavioral variables as possible s/s of pain
Vocalization
crying with apneic spells
whimpering
groaning
moaning
Behavioral variables as possible s/s of pain
State changes
sleep/wake cycle
activity level
agitation or listlessness
Behavioral variables as possible s/s of pain
Bodily Mvmts
limb withdrawal
swiping
thrashing
rigidity
flaccidity
clenching fists
- also in adolescents
Behavioral variables as possible s/s of pain
Facial expression
Eyes tightly closed or opened
Mouth opened, squarish
Furrowing or bulging of brow (together)
Quivering of chin and tongue
nose bulging
Deepened nasolabial fold
Of the behavioral variables which one is the most reliable?
facial expression
Infants behavioral variables in pain
loud inconsolable crying
facial expression (furrowed eyebrows, eyes closed, mouth open)
decreased appetite
Young children’s behavioral variables in pain
Loud 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 behavioral variables in pain
stalling
muscular rigidity
restless
sleep disturbances
Adolescents behavioral variables in pain
Withdrawn
Decreased activity
Increased muscle tension (rigidity)
Observe for specific behaviors that indicate the location of pain
Pulling ears - infection
Rolling head from side to side - ear infection
Lying on the side with legs flexed on the abdomen - abd pain
Limping - extremity pain
Refusing to move a body part - extremity pain
Physiologic Signs of pain in the neonate
increase HR, RR, B/P
shallow respirations
decrease vagal nerve tone (shrill cry) decrease pallor or flushing
diaphoresis, palmar sweating
low O2 saturation
Increased muscle tone
EEG changes
Physiological indicators of acute pain
Dilated pupils
Increased perspiration
Increased rate/ force of heart rate
Increased rate/depth of respirations
Increased blood pressure
Decreased urine output
Decreased peristalsis of GI tract
Increased basal metabolic rate
fight or flight
Physiologic measures should only be used as adjuncts to
self report of pain and behavioral observation
Physiologic indicators do not differentiate from pain response and other forms of
stress
Acute Pain activates
body’s fight or flight stress response
When pain persists, body begins to
adapt and there is a decrease in the sympathetic responses
In chronic pain, stress response is
absent or diminished
How do you secure the family’s involvement?
parents need info about assessing pain and using interventions to relieve pain
parents’ presence during painful procedures is desirable for relationship
- talk and hold
By taking the cause of pain into account the nurse is
anticipating pain when you know the illness or injury is painful
What is the golden rule of pain in children
What is painful to an adult is painful to an infant and child unless proven otherwise
The only reason to assess pain is to
take action to relieve the pain
After the intervention of pain,
assess child’s response to pain relief measures
When do you assess IV analgesics
after 5 minutes and 15 minutes
When do you assess PO analgesics
30-60 MINUTES
Do you tell the parents about the reassessment of pain after receiving the analgesics?
yes, reassure the parents the duration of the pain interventions
When Can a child use a pain scale?
At 3
What temperament makes it more difficult to see pain level?
Easy and slow to grow
What temperament makes it harder to figure out where on the pain level they are due continuous painful expressions?
Difficult
