Quiz 1: Pain and Emergency Care/Management Flashcards
1
Q
Pain Assessment Tools: Requirements
A
- Need to use appropriate tool for developmental level.
- Use the same tool each time assessing pain: decreases confusion and increases consistency.
2
Q
Pain Assessment Tools include
A
- FLACC (one of the most common)**
- FACES Pain Rating Scale (one of the most common)**
- Adolescent and Pediatric Pain Tool (APPT)
- CRIES Pain Scale
- COMFORT Behavior Scale
- Numeric Rating Scale
- The Oucher
- Poker Chip Tool
- Visual Analog Scale (VAS)
3
Q
Adolescent and Pediatric Pain Tool
A
- Three-part tool composed of a body outline, an intensity scale and a pain descriptor word list.
- Used in 8-17 years
4
Q
CRIES Pain Scale
A
Five behavioral categories:
- Crying
- Requires oxygen for SaO2 <95%
- Increased vital signs
- Expression
- Sleepless
0-2 for each with total score from 0-10. A higher score indicates greater pain or distress.
Used in neonates 0-6 months
5
Q
Comfort Behavior Scale
A
Six categories are score:
- Alertness
- Calmness/Agitation
- Respiratory response (if on ventilator) or Crying (if breathing spontaneously)
- Physical Movement
- Muscle Tone
- Facial Tension
1-5 for each category with total score from 6-30.
A higher score indicates greater pain or distress.
Used in infants and children in critical care settings.
6
Q
Pain in a neonate/infant
A
- Have immature control of nervous system
- May have a higher pain intensity -> d/t having lower pain threshold.
7
Q
What can indicate pain in a neonate/newborn?
A
- Facial expressions -> considered most consistent cue
- Different type or duration of cry -> higher pitched, tense, and harsh. (Look toward the parent to help differentiate between the child’s cry’s)
- Rapid change in behavior
- Infants may thrash extremities and exhibit tremors, pull away from nurse.
8
Q
Pain in toddlers
A
- Generalized site association -> child will most likely say “it’s my arm” instead of pointing to exact location.
- Use words the child is familiar with -> ask the parents what word is used in the house to describe hurting.
9
Q
What can indicate pain in toddlers?
A
- Can be “ouch”, “hurt”, or “owie”
- May delay procedures
- May run from nurse
- May show regression** -> very common!
10
Q
Pain in preschoolers
A
- Relate to the present ONLY** -> can only tell what is going on right here and right now -> can intensify pain experience
- Think pain will magically go away**
- May think pain is a punishment -> they are constantly hearing no at this age because they are learning consequences**
- Fear body mutilation** (i.e if they get cut and bleeding they think all of their blood will drain from their bodies and having a simple bandaid will help relieve this feeling.
- May struggle to try to escape procedures
11
Q
Preschoolers tend to be
A
Egocentric
12
Q
Pain in school age children
A
- Can describe, locate and quantify pain.
- May overreact to injury/illness -> fears bodily injury and has awareness of death.
- May attempt to bargain or procrastinate to delay painful procedures (you are taught how to get your way at this age)**
13
Q
What can indicate pain in a school-age child?
A
Nonverbal cues -> stiff body posture, may withdraw or quietly sob.
14
Q
Pain in adolescents
A
- Can describe pain and quantify pain intensity
- Can express feelings about their pain but only related to what they want the outcome to be.
- Egocentric: may tend to think others focus on their behaviors and may suppress manifestations of pain.
- Expect you to know when they need medication, even if not asked (expects you to read their minds)
- Have fewer outward signs of pain
- May not admit to pain if it will ruin their plans with peers such as going out over the weekend.
15
Q
FLACC Scale
A
Five behavioral categories
- Faces
- Legs
- Activity
- Cry
- Consolability
Each score from 0-2, resulting in a total score of 0-10.
A higher score indicates higher pain or distress.
Used in infants, proverbial/nonverbal children
16
Q
Practice How to Do FLACC Scoring
A
..
17
Q
FACES Pain Rating Scale
A
- Six cartoon faces with neutral to gradually increasing painful expressions, corresponding to an analog scale with words ranging from a happy face (0; No Hurt) to a crying face (5 or 10; Hurts worst) Accommodates a 0-5 or 0-10 system.
- Used in children 3 years of age and older.
18
Q
Numeric Rating Scale is used in children of what ages
A
9 years and older
19
Q
The Oucher
A
- A poster with a 0-100 scale for older children and a six picture photographic scale for younger children who cannot count to 100.
- 0 is no pain and 100 is the greatest pain.
- Five versions available: Caucasian/white, Asian (boy or girl), First Nations (boy or girl), Hispanic and African-American/black.
- Used in children 3-12 years of age.
20
Q
Poker Chip Tool
A
- Four poker chips are used, with each chip representing a piece of hurt.
- One poker chip represents a little hurt, and four chips represent the most hurt the child could have.
- Used in children 4-12 years of age.
21
Q
Visual Analog Scale
A
- Usually a 10-cm line with one end representing “no pain” and the opposite end “the worst pain”
- Used in children 7-18 years of age.
22
Q
Non-pharmacological Interventions for Pain in Children
A
- Parental support
- Kangaroo care -> skin to skin contact -> a lot in NICU
- Pacifier/Oral sucrose -> need order for sucrose
- Rocking
- Distraction -> do not discount pain
- Play
- Guided Imagery
- Child Life Specialist
- Muscle relaxation, holding, massage, warm or compress.
23
Q
Pharmacological Interventions for Pain in Children: Methods
A
-Analgesic
-PO
-Rectal
-Intranasal
-Topical
-Transdermal
-IV, IM, SQ
-Epidural
BEST ROUTE IS ORAL; BECAUSE THIS IS WHAT THEY ARE GOING HOME WITH
24
Q
Pharmacological Pain Interventions: What do you need to monitor?
A
- Monitor temperature after medication.
- For opioids, monitor respiratory and pulse ox.
25
What drugs are used to treat pain in children?
- Acetaminophen
- Aspirin
- NSAIDs: Ibuprofen, Ketorolac
- Opioids: Morphine, Codeine
26
Pain Relief in Children: Acetaminophen
- Most commonly used for any age group.
- Used for analgesic for mild-moderate pain and fevers.
- Can give IV Tylenol for fever but don’t want to do rectal. PO is always better.
27
Overdose of acetaminophen can lead to
Hepatic damage
28
Pain Relief in Children: Aspirin
Not recommended for kids d/t Reye’s Syndrome.
29
Pain Relief in Children: NSAIDs
Preferred drugs to treat bone and inflammatory pain associated with bone injuries, arthritis and cancer.
30
Adverse effects of opioids
- Constipation
- Pruritus
- N/V
- Cough suppression
- Urinary retention
- Can produce respiratory depression/sedation -> monitor respiratory and put on pulse ox.
31
Pain Relief in Children: Morphine
- Naloxone is antidote.
- Reaches peak 10-20 minutes after IV administration (1 hour after oral)
- Max RR depression can occur 7 minutes after IV administration -> give Naloxone.
32
General guidelines when dealing with emergencies
- Communicate calm confidence
- Establish a trusting relationship
- Encourage the caregivers to stay with child
- Tell the truth
- Provide incentives and rewards
- Assess the child’s unspoken thoughts/feelings
- Coping Mechanisms
33
Emergency Care General Guidelines: Establish a trusting relationship
- Make eye contact
- Check back with family -> provide frequent updates. If the caregivers feel confident they are being informed, they are less likely to make demands for additional attention and information.
- Provide comfort measures.
34
Emergency Care General Guidelines: Tell the truth
- Especially about the condition of the child.
- DO NOT tell them “everything is going to be okay.”
- You can say “I don’t know but we are doing everything that we can.”
- For the child, give them information of what will occur by describing sensations -> “this will feel cold on your arm”
35
Emergency Care General Guidelines: Provide incentives and rewards
- I.e stickers. (But NEVER food)
| - Developmentally a rewards for doing a good job.
36
Strategies when communicating if emotional crisis of caregiver doesn’t involve violent or abusive behavior:
- Speak in simple sentences, use no more than 5 words with no longer than -5 letters → “Let’s sit down over here”
- Encourage to move to quiet place
- Encourage to express feelings
- Set limits, avoid yes/no responses.
37
Working with children in emergencies: Infants
- Allow the use of a pacifier.
- Use a quiet, soothing voice.
- Touch, rock, or cuddle the infant. Holding the infant securely or swaddling a young infant can also be comforting.
- Keep the infant warm; if the infant must be left undressed, use warming lights to ensure a comfortable temperature.
- Allay parents’ fears so they will not be communicated to the infant.
- Remember that infants feel pain
38
Working with children in emergencies: Toddlers
- Give treatments and perform procedures with the toddler sitting up on the stretcher or examining table or on the parent's lap.
- Perform the most distressing or intrusive parts of the examination last.
- Reassure family members as much as possible; the child will benefit from their confidence.
- Allow the child to have familiar objects (transitional objects) such as a blanket, doll, or toy to help feel safe.
- Keep frightening objects out of the child's line of vision. Also try to keep machines that make loud noises away.
- Praise (e.g., “You are being so brave”) and distraction (e.g., bubbles, puzzles) will decrease anxiety and increase cooperation
39
Working with children in emergencies: Preschoolers
- Explain a procedure or treatment a few seconds rather than minutes beforehand, because allowing the young child time to think about it may result in frightening fantasies or exaggerations.
- Talk to preschool children throughout procedures, describing the sensations they are feeling or will feel and telling them how they can help.
- Distract the child with noises or bright objects. Counting with some preschool children might help calm them during procedures.
- Avoid criticizing the preschool child for crying, struggling, or fighting during a procedure.
- Reassuring a child that the child did try his or her best to cooperate will help to build a positive self-image.
- Encourage the preschool child to talk about how the illness or injury occurred. If the child is inappropriately taking responsibility for the illness or injury, try to reassure that the child is not to blame for the situation.
- Remember that preschool children can seem to understand more than they actually do. Health care providers often overestimate understanding in a child of this age, so be sure to explain things in words the child understands.
- Use positive terms, such as “make better” and “help,” and avoid more frightening terms, such as “shot” and “cut.”
- Use adhesive bandages over small wounds and injection sites. Preschool children might imagine their blood leaking out through puncture wounds
40
Working with children in emergencies: School-age children
- Offer simple choices whenever possible to help the child feel more in control. The school-age child is capable of deciding in which arm to have an injection or in which hand to hold a nebulizer.
- Talk directly to the child, explaining procedures in simple terms.
- When explaining treatments or care options to the parent, include the child.
- Ask the child about the level of understanding and allow time for questions.
- Address the child's fears or concerns directly rather than treating them as foolish or inconsequential.
- Give rewards, such as a sticker or an inexpensive toy, after a procedure regardless of the child's behavior. Think of this gesture as a reward for undergoing the procedure, not as a judgment of “good” or “bad” behavior.
41
Working with children in emergencies: Adolescents
- Preserve the adolescent's modesty; offer adolescents a choice regarding whether they want their parents present when obtaining history and during the examination.
- Consider the legal issues regarding the right to privacy for pregnant adolescents and adolescents with sexually transmissible diseases.
- Provide an opportunity for questions.
- Listen to the adolescent's concerns nonjudgmentally and without belittling the young person.
- Developing a teasing relationship with an adolescent is often a temptation, but this has potential for harm; the adolescent is easily embarrassed.
- Explain procedures or treatments carefully and allow choices. Adolescents are capable of complex abstract thinking and can make intelligent and reasoned decisions about their own care
42
Primary Assessment in Pediatric Emergencies: ABCDE
```
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure
```
43
Primary Assessment in Pediatric Emergencies: Airway Assessment
- Patency
- Positioning for air entry
- Audible sounds
- Airway obstruction (blood, mucus, edema)
44
Pediatric Differences: Airway
- The child's airway is narrower than an adult's = easily obstructed
- Infants are preferential nasal breathers for the first several months of life therefore, nasal secretions -> respiratory compromise.
- More susceptible to infectious respiratory diseases -> risk of airway obstruction.
- Mucus and edema can cause more obstruction than in a wider airway.
45
Pediatric Differences: How does the tongue affect the airway?
The tongue is relatively large -> easily fall into the airway in the unconscious child.
46
Pediatric Differences: How can the larynx affect a child’s airway?
The larynx is higher and more anterior -> risk of obstruction and aspiration.
47
Pediatric Differences: How can the submandibular area affect a child’s airway?
The submandibular area is softer and can be more easily compressed to occlude the airway.
48
What is an early sign of hypoxia in children?
Altered mental status
49
Primary Assessment in Pediatric Emergencies: Airway Nursing Implications
- Allow the child to maintain a position of comfort or manually position the airway (jaw thrust or head-tilt/chin-lift);
- Avoid flexing or hyperextending the neck
- Use spinal immobilization and airway adjuncts as required.
50
Primary Assessment in Pediatric Emergencies: Breathing Assessment
- Decreased LOC
- Increased or decreased work of breathing
- Nasal flaring
- Use of accessory muscles of respiration (retractions)
- Rate, pattern, quality, oxygen saturation
51
Pediatric Differences: Breathing
- The chest wall is thin, softer, and more compliant.
| - Have higher metabolic rates and increased oxygen demand -> Hypoxia occurs more rapidly
52
Pediatric Differences: How can rib alignment affect a child’s breathing?
Rib alignment is more horizontal. The younger child is more susceptible to respiratory distress and failure
53
Pediatric Differences: How do retractions affect a child’s breathing?
Retractions commonly occur with respiratory distress and can compromise the ability to increase tidal volume.
54
Pediatric Differences: How can pressure above or below the diaphragm affect a child’s breathing?
Pressure above or below the diaphragm can impede respiratory effort.
55
Primary Assessment in Pediatric Emergencies: Breathing Nursing Implications
- Provide supplemental oxygen
- Initiate assisted ventilation with bag-valve-mask ventilation device, and prepare for intubation as indicated
- Provide gastric decompression with orogastric or nasogastric tube
- Provide comfort measures; encourage family presence to decrease anxiety.
56
Primary Assessment in Pediatric Emergencies: Circulation Assessment
- Skin color
- Temperature and capillary refill (<2 sec)
- Rate and strength of peripheral and central pulses.
57
Pediatric Differences: Circulation
- Circulating blood volume per body weight is much larger than an adult's, even though actual blood volume is much smaller.
- Therefore small volume losses have more severe circulatory consequences.
- Increased fluid is located in the extracellular compartment -> rapid fluid shifts.
- A higher metabolic rate and oxygen demand requires an increased heart rate
58
What is the first compensatory mechanism for decreased oxygenation in children?
Tachycardia - NOT hypotension
59
Primary Assessment in Pediatric Emergencies: Circulation Nursing Implications
- Control bleeding through application of direct pressure
- Obtain vascular access; initiate volume replacement
- Perform chest compressions
- Defibrillate or provide synchronized cardioversion
- Initiate drug therapy.
60
Primary Assessment in Pediatric Emergencies: Disability Assessment
- LOC or activity level
- Response to the environment (especially caregivers)
- Pupillary response
61
Pediatric Differences: Disability
- A larger head/body ratio and weak neck muscles contribute to more serious head injury from shaking or impact.
- The anterior fontanel remains open until approximately age 18 mo. Therefore, signs of increased intracranial pressure (which may indicate underlying traumatic brain injury) may be delayed.
- A thinner skull predisposes the child to more severe injury.
- Nerve myelinization is incomplete during infancy; unmyelinated tissue is more vulnerable to shearing injury.
62
Primary Assessment in Pediatric Emergencies: Disability Nursing Implications
- Treat the underlying cause (e.g., signs of increased intracranial pressure; fluid or blood volume deficit; hypoglycemia; hypothermia; hypoxia);
- Compare assessment with parent's perception (a deeply sleeping child may be difficult to arouse, which is “normal” to caregivers).
63
Primary Assessment in Pediatric Emergencies: Exposure Assessment
To identify underlying injuries or additional signs of illness
64
Pediatric Differences: Exposure
- Indications of communicable diseases: Bulging fontanel, periorbital edema, unusual rashes, and edema or exudate in the pharynx
- Child abuse: Bruising, unusual burns, vaginal tearing, rectal bleeding
- Swelling, deformities can indicate underlying trauma to vital organs.
65
Primary Assessment in Pediatric Emergencies: Exposure Nursing Implications
Remove all clothing, including diapers; save any clothing needed for evidence; maintain an appropriately warm environment.
66
Secondary assessment also includes:
Diagnostic tests
67
H-Head to toe assessment
```
S- S&S
A- allergies
M- medications taken
P- prior illness or injury
L- last meal and eating habits
E- events surrounding injury/illness
```
68
Ingestions
- Occurs most often in children 1-5 years because they are curious at mobile at this age**
- Deliberate ingestions from adolescents: tends to occur as a result of alcohol, prescription and nonprescription drugs.
69
Poisonings
- 90% of all poison exposures occur in home.
| - Most poisonings occur orally; the rest can be ocular, dermal, inhalation, parental and envenomation.
70
Management of Ingestion and Poisoning
1. ABCDE and stabilize child**
| 2. Then remove poison, prevent absorption and limit complications.**
71
Ingestions and Poisonings: Acetaminophen
- Common in household and are in big bottles: adolescents will reach for and try to overdose.
- Can cause liver damage.
72
Treatment for Acetaminophen Overdose
- Antidote: Mucomyst (IV runs for 24 hours)
- IV Fluids
- Activated charcoal: sometimes through NG tube or drink; only works if still in stomach.
- Sodium restricted, high calorie, high protein diet: helps the process of excretion to speed up.
73
Ingestions and Poisonings: Corrosives
- Common in little ones
| - Extent of damage depends on substance -> burns going down (DO NOT INDUCE VOMITING AT HOME -> WILL CAUSE MORE BURNING)
74
What do we worry about with corrosives?
- Edema
- Difficulty swallowing
- Respiratory distress
75
Treatment for Corrosives
- IV Fluid while NPO
- Stomach can be pumped
- Steroids, ABT, NG Tube feedings
76
Lead Poisoning
- Often silent
- If not treated, can lead to neurological damage.
- Serum Levels determine treatment.
77
Lead Poisoning: When is it tested?
-Blood tested in certain age groups -> by the time the children can move around, test for lead.
78
What age does lead poisoning usually start?
Usually starts at 18 months of age: oral stage, putting everything in their mouth.
79
What must you worry about in relation to lead poisoning?
Must worry about lead content in soil, old pain and objects from other countries.
80
Toxic effects of lead poisoning occur in
Bone marrow, nervous system and kidney.
81
Treatment for Lead Poisoning
- Serum levels determine treatment
| - Chelation therapy; inpatient.
82
Ingestion and Poisoning Assessment
- Result is often shock -> monitor
- BP
- Tissue perfusion
- Mental status
- Urine output
- Frequent assessment
- Respiratory is often more sensitive in children
83
How does pediatric compensation differ from that of an adult?
- Adults are driven by blood pressure.
| - Pediatric patients compensate with the respiratory system first: increased RR, increased HR.
84
If RR drops in a pediatric patient
FREAK OUT they will code before their BP changes
85
Symptoms of Lead Poisoning
- Headaches
- Irritability
- Reduced sensations
- Aggressive behavior
- Difficulty sleeping
- Abdominal pain
- Poor appetite
- Constipation
- Anemia
86
Additional complications of lead poisoning in children
- Loss of developmental skills
- Behavior, attention problems
- Hearing loss
- Kidney damage
- Reduced IQ
- Slowed body growth
87
Common lab tests ordered for possible toxic exposure or ingestion
- Serum glucose level
- Toxicology analysis of: urine, serum and stomach contents.
- Blood gases and chest radiographs: if hypo-ventilating, respiratory distress, hydrocarbon exposure (gas), bleach.
- Baseline liver enzymes and kidney function.
88
Environmental Injuries include
- Animal/human bites
- Snake and spider bites
- Submersion injuries
89
Animal/Human Bites
- Involves soft tissue damage
- Most injuries in head and neck region (think development)
- High risk of infection if skin is broken -> mouths have bacteria.
90
Animal/Human Bites: Treatment
- Irrigation and debridement if necessary
- Keep extremity in dependent position
- Give tetanus if indicated
- Rabies treatment → if bitten by a wild animal (ex raccoon, rat, skunk) start rabies tx ASAP
91
Snake and Spider bites
- Envenomation**
| - Small children -> bitten on hands and lower extremities.
92
Treatment for Snake Bites
- Antivenin therapy -> more effective when given with 4-6 hours after injury.
- Mainstay of treatment of snake bites
93
Treatment for spider bites
- Supportive treatment: Monitor how they are doing, vitals, fluid and electrolytes.
- No antivenin for spiders (except brown recluse which is indigenous in our area)
94
Envenomation
...
95
Management of Snake and Spider Bites
- Measure extremity circumference -> same place every time every 20-30 minutes** (Draw on skin; a line above and below where you’re measuring. Tell parents not to wash off)
- Fluids and Supportive
96
Submersion Injuries include
- Drowning
| - Near drowning
97
Drowning
Submersion that results in asphyxia (no oxygen) and death within 24 hours.
98
Near Drowning
If child survives longer than 24 hours.
99
Submersion Injuries
- Most occur in residential swimming
| - Alcohol is usually a factor in teenage drowning
100
What are factors that contribute to the prognosis (submersion injuries)?**
- Age → younger the better → younger can hold breath for longer, heal faster, freak out less
- Submersion time → less time better
- Water temperature → colder the better → cold water decreases metabolism
- Elapsed time before resuscitation efforts → quicker better
- Neurologic status
101
Submersion injuries affect what systems first?
- Affects respiratory system first -> always look at first (ABC’s)
- Neurologic system is a secondary factor
102
Poorest prognosis for submersion injuries
-Submerged longer than 10 mins
-CPR longer than 24 minutes
-Arrived at ED in deep coma
GCS 5 or less
-Did not regain consciousness within first 48-72 hours of hospitalization
103
Pathophysiology of Heat Exhaustion
- Increased loss of body fluids
| - Increased blood flow to the skin -> decreased O2 and blood flow to vital organs
104
Clinical Manifestations of Heat Exhaustion
- Heavy sweating
- N/V, dizziness, fainting
- Exhaustion
- Headache
- Cramps
- Cool, moist, or flushed skin
- Core body temp slightly elevated
105
Treatment for Heat Exhaustion
- Move to cool environment
- Apply cool moist cloths to skin
- Remove clothing or change to dry clothing
- Elevate legs
- Oral rehydration fluids (if not altered mental status or vomiting)
106
Heat-Related Illness includes
- Overexertion
- Heat exhaustion
- Heat stroke
107
Children involved in physical activity
- Sweat less
- Create more heat in proportion to their body size and weight
- Take longer to adapt to warmer environments.
