Vital Signs, Pain Assessment and Communication with Pediatrics Flashcards
first step in assessing pain
understanding their previous experience with pain
the assessment tool used for pain severity is dependent on the child’s __
- age
- cognitive development
- ability to communicate
older school age children typically report the severity of their pain on what scale?
(numeric) 0-10 scale
- 0 is no pain, 5 is moderate pain, 10 is worst pain possible
what is the verbal pain scale?
mild, moderate, severe
what is the wong-baker faces pain rating scale?
uses 6 faces, each representing a different level of pain
- smiling face = no pain
- crying face = worst pain
- child points to the face that depicts their pain
- used as young as 3 years old (often used in older preschoolers)
the most reliable indicator of pain
patient’s own report
what observable behaviors may be indicative of pain in a person that cannot verbally express their pain?
- irritability
- restlessness
- moaning
- grimacing
premature infant pain profile (PIPP)
a scoring system for preterm infants that uses
- facial expressions
- behaviors
- vital signs
to determine pain levels
FLACC scale
Facial expression
Leg movement
Activity
Cry
Consolability
- measures pain in infants and children
- used with patients with CI up to age 19
- scores 0-10
comfort scale
measures distress in unconscious & ventilated infants, children, and adolescents using indicators such as
- blood pressure
- muscle tone
- facial tension
pain characteristics
- achy vs. sharp
- what makes pain better/worse
- how pain keeps from usual activities
pain characteristic information is gathered by the nurse from who?
- depending on the patient’s age/cognitive ability, either the patient or their caregivers
nursing care to pediatric patients experiencing pain includes
- pharmacologic
- non-pharmacologic
*has to be appropriate for patient’s age and developmental stage
pharmacologic interventions to pain
- Mild-Moderate pain: non-opioids (acetaminophen, NSAIDs)
when administering pharmacologic interventions, the nurse must do what before and after? why?
assess for pain before and after
- measures the effectiveness of the intervention
what do you have to monitor when giving your pedi patient opioids?
- constipation
- pruritus
- nausea
- vomiting
- sedation
- respiratory depression
non-pharmacologic interventions are used to ___
- help decrease pain perception
- decrease feelings of anxiety and fear
pain is
a feeling of discomfort and an emotional experience
- common in all age groups
optimal pain management is achieved when the nurse
- completes age-appropriate pain assessments
- self report scales
- objective measures
effective management of pain in children is
tailored to the individual
- includes pharmacologic and non-pharmacologic interventions
respiratory rate in infants and young children should be counted for how long? why?
- 1 full minute
- young children and infants have irregular breathing patterns
the ___ child, the ___ the respiratory rate will be
younger children have higher RR
assessing heart rate for children <2 years old
auscultate apical heart rate for 1 minute
- stethoscope directly on patient’s chest where the apex of the heart is
at what age can you start palpating the radial pulse to determine heart rate?
age 2
the ___ child, the ___ the heart rate will be
younger children have higher heart rates
temperature in children can be measured using what routes?
- temporal: >3 months
- axillary: <3 months
in children, where do we want the SpO2 level to be?
> 92%
- some exceptions (ie cardiac patient with congenital heart defect)
blood pressure should be taken when?
when the child is calm
- to prevent a falsely high reading
blood pressure cuff placement
- on an upper extremity
- make sure it is the appropriate size for the patient
if the BP cuff is too small, how will the reading be affected?
inappropriately high BP reading
if the BP cuff is too large, how will the reading be affected?
inappropriately low BP reading
how can you determine if the patient’s BP is normal? (hint: equation)
SBP = 70 + (age in years x 2)
blood pressure increases with increasing ___ and ____
height and weight
- larger child will have a slightly higher BP than a smaller child
what is the last vital sign to change in a really sick child?
blood pressure
if a pedi patient has an abnormal HR and RR, but normal BP, this could be indicative of ___
could still be a sign for potential clinical decline
infant (0-12 months): normal heart rate
75-130
infant (0-12 months): normal respirations
25-35
infant (0-12 months): normal blood pressure
systolic: 65-100
diastolic: 45-65
toddler (1-3 years): normal heart rate
65-100
toddler (1-3 years): normal respirations
25-35
toddler (1-3 years): normal blood pressure
systolic: 90-105
diastolic: 50-65
preschooler (3-6 years): normal heart rate
65-100
preschooler (3-6 years): normal respirations
25-30
preschooler (3-6 years): normal blood pressure
systolic: 95-110
diastolic: 55-70
school-age (6-12 years): normal heart rate
58-90
school-age (6-12 years): normal respirations
20-25
school-age (6-12 years): normal blood pressure
systolic: 100-115
diastolic: 60-75
adolescent (12-18 years): normal heart rate
50-90
adolescent (12-18 years): normal respirations
15-20
adolescent (12-18 years): normal blood pressure
systolic: 110-125
diastolic: 70-85
temperature range: rectal
97.9-100.4F
36.6-38C
temperature: oral
95.9-99.5F
35.5-37.5C
temperature: axillary
94.5-99.1F
34.7-37.3C
temperature: tympanic
96.4-100.4F
35.8-38C
temperature: temporal
97.9-100.4F
36.6-38C
hypotensive systolic BP in infants (1-12 months)
<70mm Hg
hypotensive systolic BP in children 1-10 years (5th BP percentile)
<70mm Hg + (age in years x 2) mm Hg
hypotensive systolic BP in children >10 years
<90mm Hg
at what age do we begin measuring BP?
3 years old
oral temp should be refrained from use on children under ___
<5 years old
rectal temp should be refrained if the child has
- diarrhea
- chemo
- recent rectal surgery
how is the tympanic temperature taken differently by age group?
<3 years pull pinna down and back
>3 years pull pinna up and back
heart rate is measured at the apical site for children
< 2 years
heart rate is measured at the radial site for children
> 2 years
- measure for 30 sec x 2
- confirm with other side- should be equal
when auscultating the apical HR, place the stethoscope diaphragm
- at 4th ICS L MCL (mid-clavicular line) for children < 7 years
- at 5th ICS L MCL for children > 7 years
S1 should be loudest at __
the apex of the heart
apnea is defined as
absence of breath for > 20 seconds
periodic breathing is
the absence of breath for 10-20 sec in infants
- normal
diaphragmatic breathing vs thoracic breathing
d: < 7 years
t: > 7 years
communication guidelines: infants
-smile
-use a soft voice
-make eye contact
-use animated facial expressions
-use tactile stimulation (rocking, holding, cuddling)
-talk out loud (as if you are talking to yourself)
-look for subtle and obvious non-verbal signs of communication (hands over face, batting ear, gagging self with fingers)
communication guidelines: toddlers
-get down to the child’s level for eye contact (squatting, crouching next to them)
-smile
-use a gentle, cheerful voice
-allow tactile manipulation of equipment and environment (when appropriate)
-offer simple choices when possible (blue vs. red shirt)
-use play/games to explain or prepare the child for the procedure
-allow the child to assist with simple and safe aspects of care (helping to move a piece of equipment or open a package)
-use direct and concrete child-friendly terms: “you’re tubie is getting a drink” (IV fluid, peg tube), “I’m giving your arm a
hug” (blood pressure cuff), “getting rid of the bugs” (alcohol swab), etc.
-look for obvious non-verbal signs of communication (pushing objects away, hiding, covering mouth)
communication guidelines: preschoolers
-use the techniques listed under toddlers and add:
-allow the child to participate in care if interested
-use of play and/ or role-playing to explain or prepare for the procedure
-encourage the child to use their words
-offer simple explanations if the child asks why questions
communication guidelines: school-aged
-allow the child to participate in care if interested
-allow choices whenever possible
-offer explanations and reasons in simple terms to answer who, what, when, why, how questions
-make eye contact
-use praise and rewards when applicable
-offer reassurance if the child is concerned about the integrity of the body being affected by care
-allow the child to decide if the parent(s) or legal guardians should be present
communication guidelines: adolescents
-“give undivided attention” (Hockenberry, Wilson, & Rodgers, 2019, p. 85).
-“be courteous, calm, honest, and open-minded” (Hockenberry, et al., 2019, p. 85).
-do your best not to overreact (Hockenberry, et al., 2019).
-avoid judging, criticizing, or offering opinions (Hockenberry, et al., 2019).
-allow choices when appropriate
-respect privacy (i.e., ask parents to leave the room if child desires)
-encourage participation in care
-use understandable language
-use active listening re: concerns/opinions
-respect autonomy but make expectations clear and be firm in approach when appropriate
-expect to ask several questions to construct one detailed answer
communication guidelines: transgender
-respect privacy
-use preferred pronouns
-use their preferred name
-use active listening re: concerns/opinions
-assess for verbal and non-verbal signs and symptoms of loneliness and depression during conversations and care
-convey a non-judgmental and caring approach
communication guidelines: cognitively impaired
-use a soft voice
-use understandable language/terms
-be clear and direct with explanations
-may be hypersensitive to light, noise, taste or smell; maintain decreased environmental stimulation
-announce any tactile stimulation before implementing (I’m going to touch your hand now,)
-use non-verbal language to communicate if preferred (sign language, picture board)
-encourage socially acceptable behaviors (waving hello or goodbye, saying hello, using manners)
-encourage the child to participate in dialogue if possible, using verbal and non-verbal methods
types of pain assessment tools
- behavioral (observational)
- self-report rating scales
- multidimensional
**whichever is used must be used consistently by all staff
pain should be assessed via behavioral observation for what age group?
infants to age 4 years
pain should be assessed using self-reporting scales for children of what age?
4+ years
NIPS stands for
neonatal infant pain scale
NIPS is
- behavioral scale
- used for birth-1 month old
- pain scores range from 0-7 (0-2 points per indicator)
- 6 indicators
6 indicators of NIPS
- facial expression
- cry
- breathing
- apnea
- legs
- alertness
NIPS total score: 0-2
none to mild pain
NIPS total score: 3-4
mild to moderate pain
NIPS total score: >4
severe pain
(NIPS) if the pain is rated a 4, what happens?
non-pharmacologic intervention with reassessment in 30 minutes
(NIPS) if pain is rated >4, what happens?
non-pharmacological intervention, possibly pharmacologic intervention with reassessment in 30 minutes
can FLACC scale be used with children with CI?
yes up until age 19
wong-baker scale: face 1
score: 0
no pain/no hurt
wong-baker scale: face 2
score: 2
hurts little bit
wong-baker scale: face 3
score: 4
hurts little more
wong-baker scale: face 4
score: 6
hurts even more
wong-baker scale: face 5
score: 8
hurts a whole lot
wong-baker scale: face 6
score: 10
hurts worst
which pain scale is culturally sensitive?
the wong-baker scale
- faces scale has facial expressions that are culturally sensitive Caucasian, Chinese, and African American
numeric pain rating scales are used for children
- 8 years and up
- can count and has number sense
pain assessment tool goals: NIPS (ideal score)
<3
pain assessment tool goals: FLACC (ideal score)
<4
pain assessment tool goals: numeric (ideal score)
<4
what should you do with every pain assessment?
vital signs
pain in children with communication or CI is assessed via the
NCCPC-r: non-communicating children’s pain checklist-revised
- score of 7 or higher is indicative of pain
or
PICIC: pain indictor for communicatively impaired children
NCCPC-r categories of assessment
- vocal
- social
- facial
- body and limbs
- physiological
- eating/sleeping
*score 0 (not at all) - 3 (very often) or NA
how would you assess chronic or reoccurring pain in a pedi?
- pediatric pain tool
- adolescent pediatric pain tool
the pediatric pain tool and the adolescent pediatric pain tool should be used when:
- difficult to isolate pain symptoms from other symptoms
- difficult to localize pain
- rating pain does not always accurately convey to others how they really feel
- need a tool that assess pain and functional disability
general observational/behavioral s/sx of pain
- crying
- guarding
- decreased sleep
- not eating
- eyes shut
- squeezing facial features
- withdrawn
general physiologic s/sx of pain
increased
- HR
- RR
- BP
- temp
*think increased Vitals
FLACC total score: 0
no pain
FLACC total score: 1-3
mild pain
FLACC total score: 4-6
moderate pain
FLACC total score: >7
severe pain
