Pain Management Flashcards
A nurse is assessing an infant. Which of the following are clinical manifestations of pain in an infant? (Select all that apply.)
a. Pursed lips
b. Loud cry
c. Lowered eyebrows
d. Rigid body
e. Pushes away stimulation
b. Loud cry
c. Lowered eyebrows
d. Rigid body
A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use?
A. FACES
B. FLACC
C. N-PASS
D. Non-communicating children’s pain check list
B. FLACC
children with communicative and cognitive impairment are at risk of what
underreporting of pain - utilize the caregiver when you can
which scale do you use for children with communicative and cognitive impairment
FLACC scale
temperament is an indicator of what
biologically based reactivity, defined as the amount of inhibitory influence on the heart by the parasympathetic nervous system indicating the amount of autonomic arousal at rest.
high levels of parental anxiety is associated with what
increased child behavioral distress and self-reported intensity of pain during painful procedures
t/f - Children may feel more comfortable displaying pain and distress when their parents are present
true
what is pain
An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
do neonates feel pain
-Infants of 25 weeks gestation have activation of the brain cortex in response to pain
-The anatomic and physiological aspects of pain transmission develop during the third trimester
what should you do during a pain assessment
-Based on child’s developmental level
-Use of pain rating scales
-Discussion with parents/caregivers
-Evidence that nurses who are trained in pain assessment manage their patient’s pain better.
what are the physiological response to pain that neonates have
-Vital signs: ^HR,BP, RR
-Oxygenation: < O2 sat
-Skin: pallor, flushing, diaphoresis
-Metabolic or endocrine changes : hyperglycemia, lowered pH, elevated corticosteroids
-Other : increased muscle tone, decreased vagal nerve tone, increased intracranial pressure
what is the behavioral response that neonates have to pain
-Vocalizations: crying (high pitched), wimpering, groaning
-Facial expression: grimaces, brows furrowed, chin quivering, eyes tightly closed, mouth open and squarish
-Body movements and posture: limbs thrashing, rigid, flaccid, fist clenching, lack of movement
-Changes in state: sleep, feeding, activity level, fussiness, irritability, listlessness
what does the physiologic pain rating scale CRIES look at
-crying
-requires O2
-increased vital signs
-expression
-sleepless
what does the N-PASS scale look at
neonatal pain, agitation and sedation scale
what does an infant in pain look like
-Body rigidity, thrashing, arching, drawing knees to chest
-Facial expression – brows lowered and drawn together, eyes tightly closed, mouth open and squarish
-Cry intensely, loudly, inconsolable
-Poor oral intake, be unable to sleep
-Hypersensitivity or irritability
-Occasional lack of response
-Reflexive withdrawing from pain (no association with approaching stimulus)
what does the FLACC pain scale look at
-face
-legs
-activity
-cry
-consolability
what does a toddler look like when in pain
-cry intensely, be verbally aggressive
-exhibit regressive behavior and withdrawal
-physically resist (pushing painful stimulus away after it is applied)
-guard painful area of body
-be unable to sleep
what do preschoolers/young children look like when in pain
-verbalize intensity of pain
-see pain as punishment
-thrash arms and legs
-attempt to push painful stimulus away (before)
-be uncooperative
-require physical restraint
-cling to parent, nurse, significant other
-request emotional support (hugs and kisses)
-understand that there can be secondary gains with pain
-be unable to sleep
what do school age children in pain look like
-Verbalize pain
-Use an objective measure of pain
-Be influenced by cultural beliefs
-Experience nightmares related to pain
-Exhibit stalling behaviors
-Have muscular rigidity such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes or wrinkled forehead.
-Include all behaviors of preschool children
-Be unable to sleep
what do adolescents in pain look like
-Localize and verbalize pain
-Deny pain in presence of peers
-Have changes in sleep patterns or appetite
-Be influenced by cultural beliefs
-Exhibit muscle tension and body control
-Display regressive behavior in presence of family
-Be unable to sleep
what does the VAS scale look at
numeric scale of 0-10
what are consequences of unrelieved pain in children
-Unrelieved pain has effects on all systems.
-Pain drains energy resources needed for growth and healing.
-Stress responses: increases in vital signs and intracranial pressure.
-Repeated painful experiences alter nerve pathways, leading to hypersensitivity to pain and an increased pain response – hyperalgesia and even hypersensitivity to light touch - allodynia
what are the principles of pharmacologic pain management that the WHO recommends
-Using a two step strategy: 1) NSAIDs, 2) Opioids
->3 mos. with mild to moderate pain = NSAIDs
-Antipyretic, anti-inflammatory & analgesic,
-First analgesic for pain r/t tissue injury (nociceptive pain)
-Safe and effective when dosed at appropriate levels with adequate frequency
-Take about 1 hour for effect (timing is crucial)
-Moderate to severe pain = Opioids
what is the optimal first pain management drug of choice
morphine
if a child cannot take morphine, what is the next drug options
dilaudid or fentanyl
how should you do pain management with children
-Early intervention.
-Starting doses should be optimal.
-Subsequent doses titrated to the response.
early, effective treatment is what
safer than delayed treatment and results in improved patient comfort and possibly less total analgesic administered
what type of medication schedule is recommended
Continuous or around the clock dosing at fixed intervals is recommended for moderate to severe pain that is expected to persist
how does preemptive analgesia help with postoperative pain
-Decreases postoperative pain
-Decreases analgesic requirements
-Decreases length of hospital stay
-Decreases complications after surgery
-Minimizes the risks for peripheral and central nervous system sensitization that can lead to persistent pain
how is sucrose helpful for acute painful procedures in infants
-Multiple studies confirming positive pain reducing effects of sucrose
-Adverse effects not reported (such as hyperglycemia, aspiration or NEC)
-24% solution 0.05-2ml given at least 2 minutes before procedures
-Analgesic effect increased with sucking on pacifier or bottle
explain why people may use EMLA and LMX
-Effective pain reduction
-30 min. application of LMX4 as effective as 60 min application of EMLA
-PIV access unhindered by either application
explain what NSAIDS are
-Analgesic, anti-pyretic and anti-inflammatory
-Side effects of nonselective NSAIDs: decreased platelet count, gastric irritation, potential for renal toxicity (with long term use)
-Tylenol similar anti-pyretic and analgesic effects; not an anti-inflammatory
-Tylenol combined with opioid beneficial for mild to moderate pain that doesn’t respond to Tylenol alone, but dosing of opioid cannot exceed dosing of Tylenol.
A nurse is planning care for a child following a surgical procedure. Which of the following interventions should be included in the plan of care?
A. Administer NSAIDs for pain greater than 7
B. Administer intranasal analgesics prn
C. Administer IM analgesics for pain
D. Administer IV analgesics on a schedule
D. Administer IV analgesics on a schedule
what are common fears about opioid use in children
-Respiratory depression
-Overdose
-Addiction
-Use by others (diversion)
what things do you need to think about regarding pharmacokinetics in children
-Half life preterm: 10-20 hours, preschool: 1-2 hours, adults 2-4 hours
-Dependent on hepatic development, ratio of liver size to overall body weight
-Other factors: renal blood flow, glomerular filtration, plasma concentrations of proteins
-Use dosing reference that differentiates between neonates, infants, children, adults
-Common errors in pediatric dosing: mg/mcg; decimal point errors, daily dose/fractional dose, dilution errors
what are side effects of opioids
-Most common side effects – constipation, sedation, pruritis, nausea/vomiting
-Uncommon side effects – respiratory depression, seizures, dry mouth, myoclonus and urinary retention.
explain opioid induced respiratory depression
-For a decrease in respiratory rate (significant change from baseline):
-Assess the sedation level – patient should be monitored
-Withhold further dosing or reduce infusion
-Stimulate the patient (shake shoulder, call by name, ask to take a deep breath)
-If the patient cannot be aroused or is apneic:
-Administer naloxone. Closely monitor patient – patient may need additional dosing.
-Patients may rapidly return to aroused state and be in intense pain.
what information do you need to know regarding patient controlled analgesia guidelines for use in children
-Use of PCA in children age 8 or older is well documented.
-The child “pushes the button”.
-Nurse or parent controlled anesthesia used rarely in specific situations, with caution and under policy
explain PCA in children
-Children who received PCA with additional background infusion had higher rates of satisfaction.
-Children receiving PCA required significantly less analgesia during the post operative period
how should you discontinue opioids in children
-Opioids must be reduced incrementally over time.
-In weaning, use signs and symptoms of withdrawal to determine dosing:
-Early: agitation, sweating, runny nose, yawning
-Later: nausea, diarrhea, abdominal cramping
what are nonpharmacological pain interventions
-Calm Environment, parental presence
-Positioning: Swaddling, pillows
-Heat and Cold
-Relaxation as well as increased or decreased blood flow
-Massage
what are complimentary therapies (CAMs) for pain
-Acupuncture
-Guided imagery
-Music/art therapy
-Biofeedback
how does atraumatic care play a role in pain
-Use a treatment room for painful procedures
-Avoid procedures in “safe places” such as the play room and the child’s bed
-Use developmentally based terminology when explaining procedures
-Offer choices to the child
-Allow parents to stay with the child for painful procedures
-Use play therapy for procedures, allowing the child to perform the procedure on a doll or toy
A nurse is preparing a toddler for an IV catheter insertion using atraumatic care. Which of the following are appropriate interventions?
a. Explain the procedure using the child’s favorite toy
b. Ask the parents to leave during the procedure
c. Perform the procedure with the child in his bed
d. Allow the child to make one choice regarding the procedure
e. Apply EMLA cream to three potential insertion sites
d. Allow the child to make one choice regarding the procedure
e. Apply EMLA cream to three potential insertion sites
what can you do for 0-2 year olds in pain
touching, stroking, patting, rocking, playing music, using mobiles over the crib
what can you do for 2-4 years olds in pain
puppet play, storytelling, reading books, breathing, blowing bubbles
what can you do for 4-6 year olds in pain
breathing, storytelling, puppet play, talking about favorite places, TV shows, activities
what can you do for 6-11 year olds in pain
music, breathing, counting, eye fixation, thumb squeezing, talking about favorite places, activities on TV shows, humor
what can you do for teens in pain
Preparation, parental presence, guided imagery, muscle relaxation, breathing, drawing, other cognitive behavioral strategies, comfort measures
A nurse is planning care for an infant who is experiencing pain. Which of the following should be included in the plan of care? (Select all that apply.)
a. Offer a pacifier
b. Use guided imagery
c. Use swaddling
d. Initiate a behavioral contract
e. Encourage kangaroo care
a. Offer a pacifier
c. Use swaddling
