UNIT 2 PAIN ASSESSMENT PEDI Flashcards
What is the definition of pain?
Pain is whatever the experiencing person says it is, existing whenever he says it does… its important to believe the patient.
Myth or Fact: Neonates & Infants do not feel pain with the same intensity as adults because a child nervous system is immature?
MYTH
Myth or Fact: Infants regardless of age, feel pain
Fact
Myth or Fact: The youngest premature infant has the anatomic and physiologic components to perceive pain or “nociception” and demonstrates a severe stress response to painful stimuli
Fact
What is nociception?
The process by which pain becomes conscious
True or false: Premature infants may have a greater sensitivity?
True
Myth or fact: Unrelieved pain in infants can permanently change their nervous system and may “prime” them for having chronic pain?
Fact
Myth or Fact: Repeated experience with pain teaches the child to be more tolerant of pain and cope with it better?
Myth
Myth or fact: Children do not tolerate pain better than adults
Fact
Myth or fact: Children’s tolerance to pain actually increases with age
Fact
Myth or fact: Children do not become accustomed to pain or painful procedures
Fact
Myth or fact: Children often demonstrate decreased behavioral signs of discomfort with repeated painful procedures
Myth– Children often demonstrate increased behavioral signs of discomfort with repeated painful procedures
Myth or fact: Children tell you if they are in pain
Myth– some can some cant
Myth or fact: Children do not need medication unless they appear to be in pain
Myth
Myth or fact: Children can tell you where they hurt.
Fact
Myth or fact: Children beyond infancy can accurately point to the body area or mark the painful site on a drawing; children as young as 3 can use the pain scales
Fact
Myth or Fact: Children do not always admit to having pain
Fact
Why would a child not admit to having pain?
- In order to avoid an injection
- Because of constant/chronic pain
- Because they believe others know about how they are feeling (egocentricity)
- Cultures– some cultures believe it is a sign of weakness to be in pain.
- Gender– men
Myth or Fact: Behavioral manifestations of pain may not reflect pain intensity
Fact
What might affect a child’s behavioral manifestations to reflect pain intensity?
- Developmental level
- Coping abilities
- Temperament, such as activity level and intensity of reaction to pain, influence pain behavior
A child with increased intensity of reaction and negative mood may look like they are….. in alot or little pain?
ALOT
Myth or fact: Infants and children have no memory of pain?
Myth
Myth or fact: Infants cry in anticipation of immunizations?
Fact
Myth or fact: Preterm infants have been noticed to associate the smell of alcohol with heel sticks and try to pull the foot away to avoid the pain
Fact
Myth or fact: Parents exaggerate or aggravate their child’s pain
Myth
Myth or fact: Parents know their child better than anyone else and are able to identify when the child is in pain
Fact
Myth or Fact: Parents want to be involved in their childs pain control?
Fact
Myth or Fact: Parents don’t need information about assessing pain and using interventions to relieve pain
Myth- Parents do need information about assessing pain and using interventions to relieve pain
Encourage parents to utilize pain scale anytime they believe their child is in pain
Myth or Fact: Parents presence during painful procedures is generally desirable for the child and parent
Fact
Myth or Fact: Children often become addicted to pain medication?
Myth
Myth or Fact: One reason for the prevalent fear of addition from opioids used to relieve pain is a misunderstanding of the difference between “terminology”
FACT
What is physial dependance?
Withdrawal symptoms when chronic use of an opioid is discontinued, or an opioid antagonist (naloxone or narcan) is given
It may require gradually reducing the dose (tapering it over several days)
What is withdrawal?
A collection of symptoms both behavioral and physiologic that occur when opiates or sedatives that have been administered for seven days or more are abruptly decreased or discontinued
What behavioral changes may we see in a child withdrawing?
Anxiety, agitation, insomnia and tremors
What CNS symptoms may present during withdrawal?
Irritability
Why GI symptoms may present during withdrawal?
N/V/D or feeding intolerance
What autonomic dysfunction may present during withdrawal?
Tachypnea, tachycardia, fever, sweating, and hypertension
What is an example of involuntary and physiologic responses to drugs
Drug tolerance
What is drug tolerance?
Need for larger dose of opioids or sedatives to maintain original effect (or more frequent doses)
- This may occur when children have been taking opioids or sedatives for several days (5-7 days)
Children can also develop tolerance to side-effects including….
- Respiratory depression
- Sedation
- Nausea
What do we need to know about narcotic addiction
Behavioral and voluntary pattern
1. characterized by compulsive drug-seeking behavior
2. Leading to overwhelming involvement with acquiring the drug
3. Use of opioid NOT for medical reasons, such as pain relief
What do we need to know about addiction related to pain treatment with opioids?
- Characterized by a persistent pattern of dysfunctional opioid use that may involve
- Adverse consequences
- Loss of control
- Preoccupation with obtaining opioids, despite adequate analgesia
True or false: Infants, young children and comatose or terminally ill children cannot become addicted to because they are incapable of a consistent pattern of drug-seeking behavior?
True
Myth or Fact: Children are not in pain if they can be distracted or they are sleeping?
Myth
Myth or Fact: Children use distraction to cope with pain, but they soon become exhausted when coping with pain and fall asleep?
Fact
Myth or fact: An infant may be experiencing pain even when laying quiet with eyes closed?
True
What does QUESTT stand for in terms of assessing pain?
Q- Question the patient
U- Use Pain rating scale
E- Evaluate behavior and physiologic signs
S- Secure family’s involvement
T- Take cause of pain into account
T- Take action and assess effectiveness
What should we consider in terms of verbal indications of pain with children?
- Must less common than in adults
- May not understand term, such as “pain”
- May speak globally, such as “I don’t feel good”
- May deny pain for fear of injection
- Cries, screams, groans, moans
- Use a variety of words to describe pain, such as owie, boo-boo, ouch, hurt, ow ow
- Know words in other languages
- Spanish: Ay ay, duele, lele, dolor
Besides the child who else can you question regarding the child’s pain?
Parents
Ask them about previous experiences with pain
What are we assessing on our initial pain assessment?
- Location
- Quality
- Intensity
- Onset, duration, variation and pattern
- Alleviating or aggravating factors
How can we have a child locate their pain?
- Mark body parts on a human figure drawing
- Point to area with one finger on self, doll, stuffed animal
What are some things to consider when using a pain rating scale?
- Select a scale that is appropriate for the child’s age & developmental level and abilities
- Teach child to use scale before pain is expected, such as preoperatively
- Use same scale with child each time pain is assessed
- Presenting physicians with objective documentation of pain, rather than opinion, is more likely to lead to a favorable change in analgesic orders
What are three categories of pain intensity scales?
- Subjective
- Behavioral
- Multidimensional
- Which have undergone reliability and validity testing
What are different types of subjective pain scales?
**= really important to know
- Wong-Baker FACES pain scale ***
- Oucher scale
- Word-Graphic Scale
- Numeric Rating scale ***
What are things to know about the Wong-Baker FACES pain rating scale?
*** Important to know this one
- 6 Drawn faces
- Continuum from smiling to tearful
- For children as young as 3 years old**
- Explain how to use the scale
- Do NOT compare the child’s face with those on the pain scale
What are things we need to know about the Oucher Pain Rating scale
This is not a scale we need to know extensively… just review this…
- 6 Photographs of a child’s face from “no hurt” to the “biggest hurt you could ever have:
- Includes a vertical scale of Caucasian, African American, and Hispanic children.
- For children 3-13
What are things we need to know about the word-graphic rating scale?
This is not a scale we need to know extensively just review…
- Uses descriptive words to denote varying intensities of pain
- Explain each of the words to the child, from “no pain” to “worst possible pain”
- For children 4 to 17
What are things we need to know about the numeric scale?
Important to know this one!!
- In order to utilize the numeric pain scale, they must be able to count and have a number concept and understand concepts
- more or less
- higher or lower
- number order
- Usually, age 5 and older– children’s hospital association says “numeric rating scales are appropriate for a child who is at least developmentally 7-8 years old
What are the 3 types of behavioral pain rating scales?
- FLACC
- Revised FLACC
- Modified FLACC
What should we know about the FLACC behavioral pain scale?
- May be used for 2 months to 7 years
- Observe 1 to 5 mins during routine care
- Add scores from 5 categories for total score
What should we know about the revised FLACC scale
***= most important
- Can be used in all children with cognitive impairment***
- Includes behaviors commonly associated with pain in cognitively impaired child
- Permits caregivers to identify pain behaviors specific to the child being assessed.
What should we know about modified FLACC scale?
1.Developed for use in mechanically ventilated patients
2. Includes additional parameters for the assessment of the cry category
3. Most appropriate for the assessment of procedural pain in the intubated child
What are different types of multidimensional pain rating scales?
- N-Pass
- NIPS
- PIP
- CRIES
What do we need to know about NPASS
*** Important one to study
N-Pass (neonatal pain, agitation, & sedation scale)
1. 23-40 weeks gestation
2. Combines assessment of pain, agitation, and sedation
3. For procedural and prolonged pain.
What do we need to know about NIPS
Review but not crucial
1.Recommended for children less than one year old (26-40 weeks)
2. Composed of 6 indicators, and each behavioral indicator is scored with a 0 or 1 except cry which is scored with a 0,1, or 2
3. Observe the neonate for one min.
What do we need to know about PIPP?
Review but not crucial
- 0-6 indicates minimal or no pain
- 7-12 indicates slight to moderate pain
- Greater than 12 indicates severe pain
- Total score is 0-21
- 24-40 weeks (HESI says 28-40)
- For procedural and post op pain
What do we need to know about the CRIES scale?
review but not crucial
- 10-point scale
- Used for neonates greater than or equal to 32-40 weeks of gestation (32-60 weeks according to HESI)
- Post-Op pain
- Consists of five physiologic and behavioral indicators, which are rated on a 3 point scale (0,1 and 2)
- If a score is 3 or greater, some interventions should initiated
- A score of 4 or greater indicates that the infant should be medicated
- Cannot be utilized on infants who are intubated or paralyzed because they cannot cry or grimace
What are possible signs of pain we may EVALUATE in infants and children: Behavior variables?
- Vocalizations
- Crying (often with apneic spells)
- Whimpering, groaning, moaning.
- State changes:
- Changes in sleep/wake cycles
- Changes in activity level
- Agitation or listlessness
- Bodily movements
- Limb withdrawal, swiping, or thrashing
- Rigidity
- Flaccidity
- Clenching of fists
- Facal expressions (most reliable)
- Eyes tightly closed or opened
- Mouth opened, squarish
- Furrowing or bulging of brow.
- Quivering of chin and tongue
- Deepened nasolabial fold
What are general signs to evaluate to find out if an infant is in pain?
- Loud, inconsolable crying
- Facial expression of pain (furrowed eyebrows, eyes closed, mouth open)
- Decreased appetite
What are general signs to evaluate to find out if a young child is in pain?
- Loud crying or screaming
- Using words such as “ouch” or “it hurts”
- Thrashing of extremities
- Clinging to parent
- Restless and irritable
What are general signs to evaluate to find out if a school-aged child is in pain?
- Stalling
- Muscular rigidity
- Restlessness
- Sleep disturbances
What are some general signs to evaluate to find out if a adolescent is in pain?
- Withdrawn
- Decreased activity
- Increased muscle tenison
What are specific behaviors that might indicate location of pain that we can observe/evaluate?
- Pulling ears
- Rolling head from side to side
- Lying on side with legs flexed on abdomen
- Limping
- Refusing to move a body part
What are some possibly physiologic signs of pain in a neonate?
1.Increased HR, RR, B/P
2. Shallow respirations
3. Decreased vagal nerve tone (shrill cry)
4. Decreased pallor or flushing
5. Diaphoresis, palmar sweating
6. Decreased o2 saturation
7. Increased muscle tone
8. EEG changes
What are some physiological indications of acute pain?
- Dilated pupils
- Increased perspiration
- Increased rate/force of heart rate
- Increased rate/depth of respiration
- Increased blood pressure
- Decreased urine output
- Decreased peristalsis of GI tract
- Increased BMR
What should we keep in mind for physiologic indicators?
Physiologic measures should only be used as adjuncts to self report of pain and behavior observation
This does not differentiate between pain response and other forms of stress
What is acute pain?
Acute pain activates body’s flight or fight stress response
What happens when pain persists….
Body begins to adapt and there is a decrease in sympathetic responses … which ultimately leads to chronic pain, stress response is absent or diminished
How can we secure the family’s involvement in treating/managing pain in children?
- Parents need information about assessing pain and using interventions to relieve pain
- Parental presence during painful procedures is generally desirable for the child and parent
- Allow parent to provide comfort… talking to them or holding them.
How long after IV analgesic might we need to reassess?
5 mins and 15 mins
How long after PO analgesic should we reassess?
30-60 mins
