Child HealthChild HealthNursingNursing

Partnering withPartnering withChildren & FamiliesChildren & Families

Chapter 18Chapter 18

Pain Assessment Pain Assessment and Managementand Management

Jane W. BallJane W. BallRuth C. BindlerRuth C. Bindler

Child Health Nursing: Partnering with Children & FamiliesBy Jane W. Ball and Ruth C. Bindler

© 2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Acute Pain- the History !Acute Pain- the History !

• Before 1970 - no formal research looking at pain management in children

• Swafford and Allen,1968: “pediatric patients seldom need medication for pain relief”

• 1974 – 13/25 children received no analgesia after surgery such as nephrectomies, palate repairs and traumatic amputations

Do children feel pain?Do children feel pain?• Pain fibers present at end of 2nd

trimester• Increased heel sensitivity post heel

sticks• Crying increases for days post

circumcision• 6 month olds-anticipate and avoid

pain

What is Pain?What is Pain?• “Pain is whatever the experiencing

person says it is, existing whenever they say it does”

(McCaffery and Pasero, 1999)

What is pain?What is pain?• " Pain is an unpleasant sensory and

emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It may be acute or chronic.

• Pain is always subjective. Enormous individual differences in response to painful stimuli exist.

• (from The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSMPC)

• Child and Adolescent Version, American Academy of Pediatrics,1996.)

What is Pain?What is Pain?• The pain stimulus is interpreted

based on the context or meaning of the pain to the individual, as well as the individual's psychological state, culture, previous experience, and a host of other psychosocial variables.

What is Pain?What is Pain?• As a result, the same noxious

stimulus may cause different amounts of pain in different individuals based on personal characteristics." – (from DSM-PC) Child and Adolescent

Version, American Academy of Pediatrics, 1996.)

Let’s review what is PainLet’s review what is Pain• Pain is a signal,

– nothing more,– nothing less

• ALL PAIN IS REAL• PAIN is PAIN,• Suffering is

Optional!

Pathophysiology of PainPathophysiology of Pain• Acute vs Chronic

Pain– What is Acute Pain?

• brief duration: usually less than 3 months

• Identifiable cause / injury / surgery or disease

• predictable end• subsides with

healing

Pathophysiology of PainPathophysiology of Pain• Acute vs Chronic

– What is chronic pain?• Peristent pain

lasting longer than 6 months that is generally associated with a prolonged disease process

Pathophysiology of PainPathophysiology of Pain• Nociceptors

– Free nerve endings at site of tissue damage– Purpose of nociceptors are to transmit pain

impulses along specialized nerve fibers,• the A-delta and C-fibers, to the dorsal horn of the

spinal cord

• Substantial gelatinosa, aka “gate-keeper”– Regulates transmission of pain and other nerve

impulses to the CNS– Located in the dorsal horn of s.c.

Pathophysiology of PainPathophysiology of Pain

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Pathophysiology of PainPathophysiology of Pain• Brain

– Once sensation reaches the brain other factors may influence pain intensity…like what?

– Pain signal transmitted through spinal pathways where perception occurs.

– Descending tracts can alter perception through the release of inhibitory neurotransmitters

Pathophysiology of PainPathophysiology of Pain• ANS

– Activated in response to pain• Tachycardia• Peripheral vasoconstriction• Diaphoresis• Pupil dilation• Increased secretion of catecholamines and

adrenocorticoid hormones

Pathophysiology of PainPathophysiology of Pain• Gate Control Theory

– Since pain and non-pain impulses are sent along the same pathways, non-pain impulses can compete with pain impulses for transmission

Types of PainTypes of Pain• Nociceptive: stimuli from somatic

and visceral structures– somatic: sharp/stinging; superficial -

dermal or epidermal layers; deep- bones or deeper structures

– visceral: abdominal organs, peritoneum and pleura

• Neuropathic: stimuli abnormally processed by the nervous system– damage to a nerve - infiltration,

compression or infection

Types of PainTypes of Pain• Somatic

– Sharp, hot, stinging– Generally well localized– Associated with local and surrounding

tenderness

Types of PainTypes of Pain• Visceral

– Dull, cramping, colicky, often poorly localized

– Tenderness locally or in the area of referred pain

– Associated with symptoms such as nausea, sweating and cardiovascular changes

Types of PainTypes of Pain• Neuropathic

– Pain descriptors – burning, shooting and stabbing

• Dysaesthesia (unpleasant abnormal• sensations)

– Hyperalgesia (increase response to a normally painful stimulus)

– Allodynia (pain due to a stimulus that does not normally evoke pain eg. light touch)

Physiological consequence Physiological consequence of Painof Pain

• Affects multiple body systems • (refer to table 18-1)

• Respiratory Changes– Respiratory Alkalosis– Decreased O2 sats– Retention of secretions

Physiologic Consequences Physiologic Consequences of Painof Pain

• Neurological– Increase in HR, blood sugar, cortisol levels, and

intracranial pressure (risk for IVH)

• Metabolic effects– Increase in fluid and electrolyte losses

• Immune System– Increased risk of infection

• Gastrointestinal– Impaired functioning

Behavioral Indicators of PainBehavioral Indicators of Pain• Restlessness and agitated or hyper-alert

state• Short attention span• Irritability• Facial grimacing, posturing, guarding• Anorexia• Lethargy• Sleep disturbance• Aggression

Assessing Pain in ChildrenAssessing Pain in Children• Behavioral

Responses and Verbal Descriptions of Pain by Children of Different Developmental Stages

• Refer to Table 18-4

• Children’s Understanding of Pain by Developmental Stages

• Refer to Table 18-3

Myths and MisconceptionsMyths and Misconceptionsaround Painaround Pain

• Active children cannot be in pain• Generally there is a “usual” amount of pain

associated with any given procedure• If children are asleep then they are pain free• Giving narcotics to children is addictive and

dangerous• Narcotics always depress respiration in children• Infants don’t feel pain• The less analgesia administered to children the

better it is for them

Why is Pain Assessment Why is Pain Assessment Important?Important?

• Provides an avenue for more effective management of pain

• Promotes communication between the child, parents and health professionals

• Supports evidence based practice• Provides continuity through the hospital• Allows children to indicate the intensity of

their pain

Challenges with Assessing Challenges with Assessing Children !Children !

• Lower levels of verbal fluency / non-verbal children

• May not verbally communicate presence of pain unless specifically asked

• Pain highly individualized • Parents often called upon to provide

pain ratings - can be different to patients perspective

Criteria For Selecting ACriteria For Selecting APain ToolPain Tool

• Established as valid and reliable• Developmentally appropriate• Easily and quickly understood• Liked by patients, families and

clinicians• Inexpensive• Appropriate for different languages

and culture

The Questt ToolThe Questt Tool• Question the child• Use pain rating tools• Evaluate behavior and physiological

changes• Secure parents involvement• Take the cause of pain into account• Take action and evaluate the results

Pain Assessment ToolsPain Assessment Tools• Newborn/ Infant:

– CRIES• Developed for use in preterm and ft infants in ICU• Measures crying, O2 sat, HR, BP, expression and

sleeplessness

– Neonatal Infant Pain Scale (NIPS)• Evaluates facial expression, cry, breathing, arms,

legs and state of arousal

– Premature Infant Pain Profile (PIPP)• Gestational age, behavioral state, HR, O2 sat, brow

bulge, eye squeeze, and nasolabial furrow; often used for procedural and post-op pain

CRIES neonatal CRIES neonatal postoperative Pain Scalepostoperative Pain Scale

• Refer to table 18-5

NIPS ScaleNIPS Scale• Refer to table 18-6• Recommended for children under 1

year old. • A score of 3 or more= pain

Pain Assessment ToolsPain Assessment Tools• Toddler

– FLACC– Oucher– Faces pain-rating scale

• Preschooler– Oucher– Faces Pain-rating Scale (usually 3 and over)– FLACC

• Acronym for face, legs, cry and consolability – Body Outline (3 and over)

Oucher Pain ScaleOucher Pain Scale

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

A B C

Faces Pain ScaleFaces Pain Scale

Pain Assessment ToolsPain Assessment Tools• School Age

– Numeric Pain Scale (9 yrs- adult)– Oucher– Faces pain-relating scale– Poker chip scale– Work graphic – Visual analogue

Pain Assessment ToolsPain Assessment Tools• Adolescent

– Numeric Pain Scale– Oucher– Faces Pain-relating scale– Poker chip– Work graphic– Visual analogue– Adolescent pediatric pain tool

Numeric Pain ScaleNumeric Pain Scale• Numeric Rating Scale

– Let’s say 0 means no pain and 10 means the worst pain anyone could have. How much pain do you have? (score 0-10)

Assessing Readiness for Use Assessing Readiness for Use of Pain Scalesof Pain Scales

• Refer to Box 18-3• Assess a chlid’s language, and

understanding of concepts• Children 2-3 years-old

– Understand more or less– No more than 3 choices on pain scale

• Only 26% of 5 year olds understand numeric scale– Which number is smaller 4 or 7?

Children with CognitiveChildren with CognitiveImpairmentImpairment

• Assessment of pain difficult• Contribute to inadequate analgesia• Merkel et al (1997)

– FLACC scale validated for cognitively impaired children

Case StudyCase Study• Tom is 10 years old and has severe

mucositis after having a BMT. He has a morphine PCA with a background infusion of 1ml/hr. He is lying very still in bed and is very reluctant to move. His mum does not want him to push the button unless he is really sore, as she has heard that morphine is really addictive.– Who is the best judge of Tom’s pain?– How would you go about assessing Tom’s

pain?– What would you tell Tom’s mum if you were

his nurse?

InterventionIntervention• Pharmacologic and Non-

pharmacologic methods of pain control

Pharmacologic Pain ControlPharmacologic Pain Control• Pain Medications include:

– Opioids– Nonsteroidal anti-inflammatory drugs

(NSAIDs)– Non-narcotic analgesics

(acetaminophen)

Pharmacologic Pain ControlPharmacologic Pain Control• Opioids

– Ex: morphine, codeine– Often for severe pain– Refer to p 575 for recommended drug

dosages and table 18-8, p 577 for S/Sx of Opioid withdrawal

– Naloxone is the reversal agent used for opioid adverse effects (hypotension, respiratory depression)

Pharmacologic Pain ControlPharmacologic Pain Control• NSAIDs and Non-opioid analgesics

– Ex of NSAIDS= aspirin, Ibuprofen, Naproxen– Ex of Non-opioid analgesics= acetaminophen

• Most commonly used for bone, inflammatory, and connective tissue conditions

• NSAIDs and opioids can be used in combo• Remember the differences b/t NSAIDs and

acetaminophen!• Refer to p 576 for drug dosages

Nursing Considerations when Nursing Considerations when administering a Pain analgesicadministering a Pain analgesic

• Always document pain level pre and post medication administration

• Also document any other nursing interventions and if they were useful

Patient Controlled Analgesia Patient Controlled Analgesia (PCA)(PCA)

• A method of administering IV or epidural analgesic using a computerized pump that is programmed by a healthcare professional and controlled by the child

• Children 5 years and older• Children should be able to push the button

and understand that this will give them pain relief.

Non-pharmacologic Methods Non-pharmacologic Methods of Pain Controlof Pain Control

• Distraction• Hypnosis• Imagery• Relaxation• Comfort measures

– Quiet presence– Music massage– Heat/cold– Baths– vibrations

Complimentary Therapies Complimentary Therapies for Pain Controlfor Pain Control

• Refer to p 579 in text• Sucrose solution• Muscle relaxation techniques• Breathing techniques• Electroanalgesia• Biofeedback• Acupucture

Pediatric Considerations in Pediatric Considerations in Disaster PreparednessDisaster Preparedness

• Impact of disaster– Psychological

• General effects• Anxiety• Stress

– fear

Pediatric Considerations in Pediatric Considerations in Disaster PreparednessDisaster Preparedness

• Impact of Disaster– Developmental considerations

• Toddler/ preschooler• School age• Adolescent

• Responses to Disasters by Children of Different Age Groups – Refer to Table 16-2 (p 523)

Pediatric Considerations in Pediatric Considerations in Disaster PreparednessDisaster Preparedness

• Preparedness– Pediatric drugs/ supplies– Advanced planning

• Medically fragile in community• Community disaster response systems• Family

– Resource package

– Anticipatory Guidance

I hope this lecture wasn’t I hope this lecture wasn’t too painful!!too painful!!