Pain Assessments Flashcards
1
Q
Newborns and young infant response to pain
A
crying
brows lowered and drawn together
tightly closed eyes
mouth open
squarish
rigid, thrash, withdrawal reflex
no relationship btw causing pain and response
2
Q
Older infant response to pain
A
crying
deliberate withdrawal from cause
pain and anger expression
physical struggle, esp. pushing away
3
Q
Young child response to pain
A
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
4
Q
School-age response to pain
A
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)
5
Q
Adolescent response to pain
A
less vocal with less restraint
More verbal in the expression “You’re hurting me”
Increased muscle tone and body control
6
Q
Manifestations of Pain in the Neonate
VS
A
increased heart rate, BP,
rapid, shallow respirations
decreased O2 Sat
7
Q
Manifestations of Pain in the Neonate
Physical
A
pale or flushed
sweating
increased muscle tone
dilated pupils
low vagal nerve tone
Increased ICP
low pH, high glucose, and corticosteroids
8
Q
Manifestations of Pain in the Neonate
Behavioral responses
A
crying
whimpering
groaning
grimace, quiver, tightly closed eyes
mouth open and squarish
limb withdrawal
thrash, rigid, flaccid
fist clenching
9
Q
Manifestations of Pain in the Neonate
Changes in sleep, nutrition, or activity
A
fussiness, irritability
listlessness
inability to sleep at times
10
Q
Nonpharmacologic Strategies for Pain Mgmt
A
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
11
Q
Instead of saying “This is going to (or may) hurt” what should you say to the child?
A
“Sometimes this feels like pushing, sticking, or pinching, and sometimes it doesn’t bother people. Tell me what it feels like to you.”
11
Q
Types of Distraction Techniques
A
audio or visual deterrents
deep breaths and blowing
bubbles
Kaleidoscopes
Use humor
with friends
12
Q
Types of Relaxation Techniques
A
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
13
Q
Types of Guided Imagery Techniques
A
Happy Places
describe details
write down script
encourage to go to a pleasurable place
combine with breathing and relaxation
14
Q
Types of + self-talk Techniques
A
positive statements
15
Q
Types of Stop Thoughts Techniques
A
+facts
reassuring
brief statements and memorize them
16
Q
Types of Behavioral Contracting Techniques
And age
A
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
17
Q
Managing Opioid Side Effects
Constipation
A
constipation: stool softeners, increase intake (prune juice, bran cereal, veggies) and exercise
18
Q
Managing Opioid Side Effects
Sedation
A
Sedation: caffeine
if persists seek alternative
19
Q
Managing Opioid Side Effects
N/V
A
ondansetron, imagery, deep and slow breathing
20
Q
Managing Opioid Side Effects
Pruitus
A
Naloxone, oatmeal baths, good hygiene,
exclude other causes of itching
change opioid
21
Q
Managing Opioid Side Effects
Respiratory depression (mild-moderate-severe)
A
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
22
Q
Managing Opioid Side Effects
Dysphoria, confusion, hallucinations
A
rule out other causes
Haldol or opioid switch
23
Q
Managing Opioid Side Effects
Urinary retention
A
eliminate antihistamines, antidepressants
Oxybutynin
In/out or indwelling cath
24
If respirations are depressed (opioid-induced)
assess sedation
reduce infusion by 25 % if possible
stimulate pt
admin O2
25
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)
26
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
27
For children > 40 kg (88lbs) dilute 0.4 mg naloxone in
10 mL sterile saline and give 0.5mL
28
Signs of opioid tolerance
decreased pain relief and duration of relief
29
Initial Signs of Withdrawal Syndrome in Patients with Physical Dependence
Lacrimation
Rhinorrhea
yawning and sweating
30
Later Signs of Withdrawal Syndrome in Patients with Physical Dependence
restlessness
irritable
tremors
anorexia
dilated pupils
goosebumps
N/V
31
Physical dependence
abrupt cessation of the opioid, or administration of an opioid antagonist, results in a withdrawal syndrome.
**does not imply addiction**
32
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**
33
Addiction
persistent pattern of dysfunctional opioid use:
adverse consequences, loss of control, preop with obtaining opioids
34
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**
35
Define Pain for a pt
whatever the experiencing person says it is, existing whenever he says it does
**BELIEVE THE PT**
36
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.
37
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
38
The youngest premature infant has the anatomic and physiologic components to perceive ___________ and demonstrates what?
nociception
39
The complete myelination of nerve pathways is not required for
pain transmission
40
Nociception
Process by which pain becomes conscious
41
Transduction
process of noxious stimuli converted to electrical signals (impulses) in sensory nerve endings
42
Transduction occurs at the site of
tissue damage
43
What is the process of pain perception
Transduction
Transmission
Perception
Modulation
44
Transmission of pain
spreading the sensation along the nerves to the CNS (ending in the brain stem)
45
Perception of pain occurs
transmission reaches the brain and is perceived as a conscious, emotional and physical experience
46
Modulation involves
changing or inhibiting the transmission of the initial impulse
- occurs after the perception of pain reaches the brain
47
Premature infants may have a
greater sensitivity
48
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
49
Unrelieved pain in infants can permanently change their nervous system and may
prime them for having chronic pain
50
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.
51
Children's tolerance to pain actually __________ with age.
increases
- some they have more pain
52
Children do not become accustomed to pain/painful procedures; they actually demonstrate an
increased behavioral signs of discomfort with repeated painful procedures
53
Children have increased behavioral signs of discomfort because
they know what it feels like
54
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.
55
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
56
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+
57
Children do/do not always admit to having pain.
do not
58
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)
59
Behavioral manifestations of pain may not reflect pain
intensity
Predominantly crying and difficult mood
60
Pain s/s may be affected by
developmental level
coping abilities
temperament (activity level, intensity of reaction, influence pain behavior)
61
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
62
A child with an increased intensity of reaction and negative mood may look like
they are in a lot of pain
63
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
64
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
65
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
66
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
67
Parental presence during painful procedures is
desirable for the child and parent
68
What can a nurse teach the parents regarding pain interventions?
nonpharmacologic measures lessen the child's pain
parental presence during procedures (Atraumatic care)
69
T/F: Children Often Become Addicted To Pain Medication.
FALSE, physical dependence if on 7 + days and need to wean off or develop tolerance
70
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
71
Physical dependence
withdrawal symptoms when **chronic use of an opioid is D/C, or an opioid antagonist (Naloxone or Narcan) is given**
72
Physical dependence may require reducing the dose of opioids
gradually (weaning off over several days without symptoms)
73
Opioid antagonist
Narcan or naloxone
74
Physical dependence develops when the pt is on opioids for how long
typically 7+ days
75
Withdrawal
collections of symptoms (behaviors and physiologic) occur when opioids or sedatives have been administered for 7 days +
**and abruptly decreased or D/C**
76
Withdrawal s/s
anxiety, agitation, insomnia, and tremors
irritable
N/V/D or feeding intolerance
HIGH HR, RR, BP, and fever
sweating
77
Involuntary physiologic responses relates to what drug effect
Drug tolerance
78
Drug tolerance
need a larger dose to maintain original effect (or more frequent)
79
Drug tolerance could occur when children have been taking opioids or sedatives for
several days (5-7)
80
Tolerance side effects
respiratory depression
sedation
nausea
Stop after initial doses
81
When do the side effects of opioids usually occur?
initial dose and improves after 2 days
82
Narcotic Addiction is what type of pattern
behavioral and voluntary
83
Narcotic Addiction is characterized by
compulsive drug-seeking behavior
84
Narcotic Addiction leads to
overwhelming involvement with acquiring the drug
85
Narcotic Addiction is the use of opioid
NOT for medical reasons (pain relief)
86
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
87
Addiction r/t pain tx with opioids involves
adverse consequences
loss of control
preoccupation with obtaining opioids despite adequate analgesia
88
What factors characterize the complex condition of addiction with opioids
genetic, psychosocial, and environmental
89
The continued use of the drug causes changes in the _______ ________ leading to
brain wiring
leads to powerful cravings and difficulty stopping the drug
90
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
91
T/F: Children Are Not In Pain If They Can Be Distracted Or They Are Sleeping.
False, distraction to cope
92
Children use what to cope with pain
distraction
93
Children use distractions to cope with pain, but soon they become
exhausted when coping with pain from energy spent up and fall asleep
94
An infant may be experiencing pain even when
lying quiet with eyes closed
95
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
96
QUEEST is what type of assessment
Multidimensional Model of Pain Assessment mnemonic
97
QUEEST
QU = vocal
E = behavioral
E = Physiologic
ST = contextual
98
What is the gold standard for pain assessment?
patient self-report (vocal)
99
Vocal assessment of pain includes what in multidimensional
Specific = self-report
Nonspecific = cry, scream, groan
100
Nonspecific vocal assessment
cry
scream
groan
101
Behavioral assessment in multidimensional
Facial expressions
rigid posture
less activity
sleep more
response to interventions
102
Contextual assessment in multidimensional
pain stimulus/ hx
**temperament**
age, sex
**culture**
significant other input
103
Physiologic assessment in multidimensional
VS
O2 change
hormonal changes
sweating
palmar sweat
104
QUESTT assessment
**Q**uestion the pt and parents
**U**se pain rating scale
**E**valuate behavior and physiologic signs
**S**ecure family's involvement
**T**ake cause of pain into account
**T**ake action and assess the effectiveness
105
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
106
Synonyms for pain in children
hurt
owwie
ow ow
booboo
ouch
don't feel good
**What do you call pain at home?**
107
Synonyms for pain in other languages
ay ay
duele
lele
dolor
108
When questioning the parents about pain what should be said?
previous experiences with pain
109
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*
110
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
111
When selecting a scale that is appropriate for a child what should the nurse take into account?
age
developmental level and abilities
112
When should you teach a child to use the pain scale?
before pain is expected (preoperative)
*however not always the case*
113
Use the _______ scale with a child each time pain is assessed
same
114
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
115
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
116
When should you reassess pain?
30-60 minutes after giving medication
117
What are the 3 pain intensity scales?
Subjective
Behavioral
Multidimensional
118
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**
119
Behavioral pain scale
assessing behaviors identified as indicators of pain
- FLACC
- Revised FLACC
- Modified FLACC
120
Multidimensional pain scale
NICU - undergone reliability and validity testing
-N-PASS
-NIPS
-PIPP
-CRIES
121
Wong-Baker FACES Pain Rating Scale
- subjective
- 6 drawn faces from smiling to tears
122
Wong-Baker FACES Pain Rating Scale
is used on what age of children?
3+ years old
123
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.
124
The Oucher pain rating scale uses
6 photographs of a child's face from "no hurt" to "biggest hurt you could ever have"
125
Oucher pain rating scale includes
vertical sale of Caucasian, AA and Hispanic children
126
The Oucher pain scale is for children
3-13 years old
127
Word-Graphic Rating Scale uses
descriptive words with vary intensities of pain
128
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"
129
The Word-graphic rating scale is used in children's ages
4-17 years old
130
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
131
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
132
FLACC stands for
Face
Legs
Activity
Cry
Consolablilty
133
FLACC is used on children's ages
2 months to 7 years
134
FLACC behavior needs to be observed for how long
1-5 minutes during routine care
135
The FLACC total score is calculated by
adding up all 5 categories
136
Pre-verbal is for
infants to 3+
137
A high FLACC score is
high pain
138
A low FLACC score means
little to no visible pain
139
The revised FLACC scale is used for all children with
cognitive impairment
140
The revised FLACC score shows the
behaviors commonly associated with pain in cognitively impaired children
- caregiver to identify pain behaviors specific to child assessed
141
The modified FLACC Scale is used in children with
mechanically ventilated pts
142
The modified FLACC scale includes
additional parameters for cry category assessment
143
Which is the most appropriate pain scale for procedural pain in the intubated child?
Modified FLACC Scale
144
N-PASS stands for
Neonatal Pain, Agitation, and Sedation Scale
145
NPASS is used in what specific department
NICU
146
N-PASS is used in what "age" of children
23-40 weeks gestation
147
N-PASS combines
assessment of pain
agitation
sedation
148
N-PASS is used in
preemies with procedural and prolonged pain
149
The N-PASS looks like what in adults
MEWS score but for neonates with assessment criteria reared towards premature pain
150
What are the assessment criteria for the N-PASS?
crying, irritability
behavior state
facial expression
extremities tone
VS (HR, RR, BP, and O2)
151
What are the best (no pain) to worst (worst pain or sedation) scores on the NPASS?
Sedation -2*5 = -10
Normal = 0 (best)
Pain/Agitation = 2*5= 10
152
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
153
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
154
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
155
NIPS stands for
Neonatal Infant Pain Scale
156
NIPS is recommended for children
less than 1 year old (26-40 weeks)
157
NIPS is composed of how many indicators
6
158
In the NIPS scale, each behavioral indicator is scored from
0 or 1 with 0,1,2 for crying
159
NIPS scale is observing the neonate for
1 minute
160
The NIPS scale best with no pain score is
0 (calm, sleep, absent)
161
The NIPS scale with worse pain score is
7 (contracted, vigorous/mumbling crying, different breathing, flexed, uncomfort)
162
NIPS score is based on
facial expression
cry
breathing
arms
legs
alertness
163
PIPP scores
minimal or no pain
0-6
164
PIPP scores
slight to moderate pain
7-12
165
PIPP scores
severe pain
12+
166
The max severe score for PIPP is
21
167
PIPP is used for
procedural and post-op pain
168
PIPP is used for what age of children?
25-40 weeks (HESI 28-40)
169
CRIES is what type of scale
10 points
170
CRIES is used for
neonates 32-40 weeks gestation
- 32-60 weeks for HESI
171
CRIES is used for
postop pain
172
CRIES consists of
5 physiologic and behavioral indicators rated from 0-2
173
On the CRIES scale, if the score is 3+, what does the nurse do?
some intervention should be initiated
174
On the CRIES scale, if the score is 4+, what does the nurse do?
indicates the infant should be medicated
175
The CRIES scale cannot be utilized on infants who are
intubated
paralyzed
bc they can not grimace or cry
176
In the CRIES scale the higher the score the
higher intervention needed
177
Behavioral variables as possible s/s of pain
Vocalization
crying with apneic spells
whimpering
groaning
moaning
178
Behavioral variables as possible s/s of pain
State changes
sleep/wake cycle
activity level
agitation or listlessness
179
Behavioral variables as possible s/s of pain
Bodily Mvmts
**limb withdrawal
swiping
thrashing
rigidity**
flaccidity
clenching fists
- also in adolescents
180
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
181
Of the behavioral variables which one is the most reliable?
facial expression
182
Infants behavioral variables in pain
loud inconsolable crying
facial expression (furrowed eyebrows, eyes closed, mouth open)
decreased appetite
183
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
184
School-age child behavioral variables in pain
stalling
muscular rigidity
restless
sleep disturbances
185
Adolescents behavioral variables in pain
Withdrawn
Decreased activity
Increased muscle tension (rigidity)
186
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
187
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
188
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**
189
Physiologic measures should only be used as adjuncts to
self report of pain and behavioral observation
190
Physiologic indicators do not differentiate from pain response and other forms of
stress
191
Acute Pain activates
body's fight or flight stress response
192
When pain persists, body begins to
adapt and there is a **decrease** in the sympathetic responses
193
In chronic pain, stress response is
absent or diminished
194
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
195
By taking the cause of pain into account the nurse is
anticipating pain when you know the illness or injury is painful
196
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
197
The only reason to assess pain is to
take action to relieve the pain
198
After the intervention of pain,
assess child's response to pain relief measures
199
When do you assess IV analgesics
after 5 minutes and 15 minutes
200
When do you assess PO analgesics
30-60 MINUTES
201
Do you tell the parents about the reassessment of pain after receiving the analgesics?
yes, reassure the parents the duration of the pain interventions
202
When Can a child use a pain scale?
At 3
203
What temperament makes it more difficult to see pain level?
Easy and slow to grow
204
What temperament makes it harder to figure out where on the pain level they are due continuous painful expressions?
Difficult
