Chapter 7: Pain assessment and management in children

Laura Salisbury RN, MSN/Ed.Chapter 7: Pain assessment and management in children

Pain AssessmentDistress behaviors: What are these?Developmental characteristics of pain response (see box 7-1, p. 159)

Three types of measures to assess childs pain:BehavioralPhysiologicSelf-reportWhen are these measures accurate? What makes them inaccurate?

Pain rating scales for ChildrenFACESFLACCOUCHERPoker chip toolWord-graphic rating scaleNumeric scaleVAS (visual analog scale)Color tool

Pain in NeonatesDifficult to assessCan only be based on physiologic and behavioral responses

Assessment tools:CRIESPIPP (Premature Infant Pain Profile)NPASS (Neonatal Pain, Agitation, and Sedation Scale)

Pain in Children with Communication and Cognitive ImpairmentAt greater risk for under treatment of painPrimary caregiver important source of informationPain measurement tools:Non-communicating Childrens Pain ChecklistPICIC (Pain Indicator for Communicatively Impaired Children)

Pain in Children with Communication and Cognitive ImpairmentCultural issues: what may affect cultural appropriateness of pain assessment?

Children with Chronic Illness and Complex PainImportant components of assessment: what are they?

Pain ManagementNonpharmacologic managementVirtual realityContainment/swaddling/tuckingNonnutritive sucking/with or without sucroseKangaroo care

Complementary pain medicine

Pharmacologic managementBased on weight until 50 kg (110 lbs)Acetaminophen (15 mg/kg)NSAIDS (10 mg/kg)OpioidsAdjuvants

Routes and Methods of Analgesic Drug AdministrationOralPCA: Patient-controlled/nurse-parent controlledTransmucosalIV/Sub-QIntramuscularIntranasal

IntradermalTransdermal/topicalEMLALATNumby StuffEpidural/IntrathecalRectalRegional nerve blockInhalation

Monitoring and treatment of side effects from opioidsRespiratory depressionConstipationPruritisNausea/vomitingSedationPhysical dependenceWithdrawalToleranceAddiction (psychologic dependence)

Evaluation of therapyPossible effects of pain in infancy/childhood

Painful and Invasive Procedures/Postoperative painUse of nitrous oxideSurgery and traumatic injury generate a catabolic statePreemptive analgesiaMultimodal analgesia

Recurrent headaches in children

Recurrent abdominal pain in children

Cancer pain in childrenPeripheral neuropathyEnd-of-life pain and sedation

Laura Salisbury RN, MSN/Ed.Chapter 22: Pediatric variations of Nursing Interventions

Informed ConsentPatient assentWhen is treatment given without parental consent?

Preparing children for proceduresDoing the procedureTreatment roomBe confidentUse distractionOK to express feelings; OK to cryAfter procedure: Allow venting, give positive reinforcement

Surgical ProceduresSurgical ProceduresAdvantages vs. disadvantages of keeping parent with child until anesthesia Preoperative sedation: necessary?Fasting before hand? (Table 22-1, p. 696)

Postoperative careSymptoms of malignant hyperthermia; how is it treated?

General Hygiene and CareSee Skin Care guidelines, box on p. 700What is epidermal stripping?How do you encourage nutrition? Fluid intake?

Controlling increased temperatureFever vs. hyperthermia: what is the difference?Fever: antipyretic FIRST, then cooling measures: dont allow shiveringAntipyretics do not prevent febrile seizuresHyperthermia: Antipyretics will not workConcerning signs: See box p. 704

SafetyAccurate identification: how?Prevent falls: how?Infection control: KNOW BOX 22-5 p. 707: types of precautions and patients requiring themThe most critical infection control practice is:How should pediatric patients be safely transported?

RestraintsBehavioral: Rarely used in pediatricsMedical-surgical: when are they used? What precautions should be taken?Temporary restraint (procedural): what is therapeutic holding?Mummy restraint, swaddle, jacket restraint, arm/leg restraints, elbow restraintsHow are children positioned for an LP?

Specimen collection Urine: how? Getting out of disposable diaper (see FYI p. 712)What is suprapubic aspiration? When is it used?Stool: How?BloodOut of saline lockArterial: do Allen test firstInfant heel puncture: how do you do it safely? Where to you punctureSputum: Nasal washing

Administration of MedicationsOral route: measure accurately! Do not mix meds with bottle; know when you can crush pillsUse of an oral syringe to get med into an infantIntramuscular: use vastus lateralis in the infant; can use ventrogluteal all ages; deltoid in older children, when small amount of med (How much can be given in a single shot in each site?)See guidelines box, p. 721

Administration of MedicationsIV devicesSaline lock: short termCentral access: Non-tunneled cathetersPICC lines

RectalRectum needs to be empty; can be difficult to get the right doseNG/OG/Gastrostomy: see guidelines p. 730Eye drops: careful not to contaminate

Fluid BalanceMaintaining fluid balance1 gram wet diaper weight=1 mL urineDealing with children who are NPO/fluid restrictedParenteral fluid

Rehydration methodsORSIV Fluid

Site SelectionAvoid dominant hand; avoid foot/leg in children who are walkingWhen rapid IV access needed, cant get IV site: Intraosseous (runs just like an IV)Secure the sitebut allow for circulation assessment distally; watch for infiltrationHow do you remove tape?What is the difference between infiltration and extravasation?

Oxygen TherapyHoodNasal cannulaOxygen tentMask not usually toleratedOxygen toxicity: retina of preterm infants; lungs damaged with excessive useWhat is oxygen-induced carbon dioxide narcosis?Pulse oximetry: Change site frequently to avoid burns, necrosis

Respiratory treatmentsAerosol therapyHandheld nebulizersMDI: use a spacer

Postural drainage: what is it? When used?Chest physical therapy: What is it? When used?

Artificial VentilationNasotracheal intubation preferred over endotracheal when possibleOnly uncuffed endotracheal tubes for children less than age 8Always humidify air/gas being delivered directly to tracheaTracheostomies: What do we watch for?Suctioning: NO MORE than 5 seconds: hyperventilate with 100% oxygen pre and post; no more than 3 passes at a time; only as often as neededWhat if tube is totally occluded or it comes out? What to do?

Alternative FeedingGavage feedingFlows in by gravityGive infants something to suck onGastrostomy tubes (G-tubes): may flow in by gravity or be put on pumpNasoduodenal, nasojejunal: When are these used? What tells us that it may be in the wrong place?Always verify placement by X-ray before first useTPN: Control risk of sepsis, watch infusion rate, assess patients tolerance

Enemas and OstomiesUse isotonic solutions; Dont use Fleet enema (not even the pediatric Fleet!)Particularly distressing for preschool child

Children can be taught to manage own ostomy appliance; adolescents especially disturbed by ostomy