Pain Assessment and Management in Children

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Pain Assessment

Three types of measures to assess childs pain:

Behavioral (FLACC Scale) Physiologic (VS) Self-report (FACES, Numeric scale)

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Pain Rating Scales for Children

FACES OUCHER Poker chip tool Word-graphic rating scale Numeric scale VAS (visual analog scale) Color tool Table 7-2
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Young Infants Response to Pain

Generalized response of rigidity, thrashing Loud crying Facial expressions of pain (grimace) No understanding of relationship between stimuli and subsequent pain

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Facial Expression of Pain

FIG. 7-1 Full, robust crying of preterm infant after heel stick. (Courtesy Halbouty Premature Nursery, Texas Childrens Hospital, Houston; photo by Paul Vincent Kuntz.)

FIG. 7-2 The face of pain after heel stick. Note eye squeeze, brow bulge, nasolabial furrow, and widespread mouth. (Courtesy Halbouty Premature Nursery, Texas Childrens Hospital, Houston; photo by Paul Vincent Kuntz.)

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Older Infants Response to Pain

Withdrawal from painful stimuli Loud crying Facial grimace Physical resistance

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Young Childs Response to Pain

Loud crying, screaming Verbalizations: Ow, Ouch, It hurts Thrashing limbs Attempts to push away stimulus

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School-Age Childs Response to Pain

Stalling behavior (Wait a minute) Muscle rigidity May use all behaviors of young child

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Adolescent

Less vocal protest, less motor activity Increased muscle tension and body control More verbalizations (It hurts, Youre hurting me)

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Pain in Neonates

Difficult to assess Can only be based on physiologic and behavioral responses Assessment tools:

CRIES PIPP (Premature Infant Pain Profile) NPASS (Neonatal Pain, Agitation, and Sedation Scale) Table 7-3

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CRIES Neonatal Pain Scale

Crying Requiring increased oxygen Increased vital signs Expression Sleeplessness

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Premature Infant Pain Profile (PIPP)

Specifically developed for premature infants Gives higher pain score to lower gestational age Gives higher pain score to blunted behavioral response

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Neonatal Pain and Sedation Scale (NPASS)

Used for 23 weeks gestation up to 100 days of age

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Pain in Children with Communication and Cognitive Impairment

At greater risk for undertreatment of pain Primary caregiver important source of information Pain measurement tools:

Non-communicating Childrens Pain Checklist PICIC (Pain Indicator for Communicatively Impaired Children)

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Children with Chronic Illness and Complex Pain

Important components of assessment:

A trusting relationship with child and family Onset of pain Pain duration or pattern Effectiveness of current treatment Factors aggravating or relieving pain Concurrent symptoms and complications Difficult to isolate pain symptom from other symptoms Rating pain does not always accurately convey to others how they really feel
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Pain Assessment Components

Onset of pain Pain duration/pattern Is current treatment effective? Factors that aggravate or relieve the pain Other symptoms and complications concurrently felt Interference with the childs mood, function, and interactions with family
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Barriers to Pain Management

Family issues and relationships Fears and concerns about addictions Lack of knowledge about pain Inappropriate use of pain medications Ineffective management of adverse effects from medications

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Pain Management

Nonpharmacologic management Complementary pain medicine Pharmacologic management

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Nonpharmacologic Pain Interventions

Distraction Relaxation Guided imagery Cutaneous stimulation

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Nonpharmacologic Pain Interventions for Infants

Containment Positioning Nonnutritive sucking Kangaroo holding

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Complementary Pain Medicine

Biologically based

Herbal or plant preparations, special diets Chiropractic, massage Bioelectric or magnetic treatments Spiritual healing, hypnosis, relaxation Homeopathy, traditional Chinese medicine, acupuncture
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Manipulative treatments

Energy based

Mind-body techniques

Alternative medical systems

Pharmacologic Methods

Nonopioids Opioids Adjuvant analgesics Tables 7-4, 7-5, 7-6

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Dosing of Analgesics

First-pass effect

Table 7-8

Titration to desired effect Route of administration and effect on dosage

Box 7-3

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PCA Mechanisms of Action

Basal rate

Purpose Patient administered Nurse or parent administered Advantages Disadvantages

Bolus doses

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Morphine

Gold standard Drug of choice for PCA 1 mg/ml typical for PCA usage (this is the strength not the dose)

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Other Opiods

Hydromorphone Fentanyl Meperidine

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Meperidine

May increase the risk of seizures due to excitatory effects on the nervous system Recommended use for brief treatment for patients who have demonstrated its effectiveness or who have allergies or uncorrectable intolerances to other opioids Max usage 48 hours or 600 mg/24 hours

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Epidural Anesthesia

Opioid

Fentanyl or Hydromorphone or Preservative-free morphine

+ Local (bupivacaine or ropivacaine) Instilled via single or intermittent bolus, continuous infusion, or patient-controlled epidural analgesia (PCEA)

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Nursing Care of Child with Epidural Anesthesia

Careful monitoring for respiratory depression Skin care around catheter insertion site Assessment of pain

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Transmucosal and Transdermal Analgesia

Fentanyl (Oralet) Duragesic patch Anesthetic creams (EMLA, LMX) Refrigerant sprays (ethyl chloride and fluorimethane) Numby Stuff LidoSite activated patch

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Local Anesthetics: Lidocaine

Side effects: stinging and burning on injection Buffered lidocaine

Decreased or eliminated stinging Decreased or eliminated stinging

Warming lidocaine to body temperature

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Timing of Analgesia

ATC vs. PRN

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Analgesia

Clock watching Addiction

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Side Effects

Respiratory depression Constipation Pruritus Nausea, vomiting Sedation Tolerance Physical dependence Table 7-7
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Tolerance

Dose must be increased to achieve the same effect May develop after 10 to 21 days Treatment

Increase dose Decrease duration between doses

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Treatment of Physical Dependence

Gradually reduce dose

One half dose q 6 hours for first 2 days Reduce by 25% q 2 days until total daily dose of 0.6 mg/kg/day of morphine (or equivalent) is reached After 2 days on this dose, discontinue opioid

May also switch to oral methadone, using one fourth of equianalgesic dose as initial weaning dose and proceeding as described above
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Patient/Family Education

Discuss educational needs surrounding use of opiates for analgesia in infants and children

Addiction/dependence Cause and effect of psychologic dependence Nursing statements to child/family and potential effects

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Evaluation of Effectiveness of Pharmacologic and Nonpharmacologic Interventions

When to evaluate?

Q 30 minutes after intervention with IV med, Q 60 minutes after intervention with PO med

Document findings Ongoing assessments

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Harmful Effects of Unrelieved Pain in Pediatric Clients

Physiologic stress responses Chronic pain syndromes

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Consequences of Unrelieved Pain in Neonates

Physiologic changes

Increased ICP, HR, RR, BP Decreased SaO2 Muscle rigidity, facial expression, crying, withdrawal, and sleeplessness

Behavioral changes

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Sedation for Nonpainful Procedures

Chloral hydrate, nembutal Careful monitoring during and after procedure Decrease stimuli after procedure Nembutal rage

Agitation during emergence

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Conscious Sedation (Minimal Level of Sedation)

Protective reflexes are maintained Able to maintain a patent airway independently and continuously Responds to physical stimulation or verbal command (e.g., Open your eyes) Cognitive function may be impaired (like with a colonoscopy)

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Moderate Sedation

Not easily aroused but responds purposefully to verbal commands, either alone or accompanied by light touch May retain partial or no protective reflexes Airway, spontaneous ventilation, and cardiovascular function may or may not be adequate without interventions (e.g., oxygen)

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Deep Sedation/Anesthesia

Cannot be easily aroused No protective reflexes Unable to maintain a patent airway; ventilatory and cardiovascular function independently may be impaired Continuous monitoring q 5 minutes

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Emergency Equipment for Moderate and Deep Sedation

Suction apparatus with catheters Oxygen source, oral and nasal airways, ETTs, laryngoscope/blades, Ambu bag/mask Medications for resuscitation and drug antagonism IV access Trained individual (MD, RN) whose sole responsibility is to monitor patient

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Painful and Invasive Procedures

Surgery and traumatic injury generate a catabolic state Increased catabolic hormones lead to alteration in blood flow, coagulation fibrinolysis, substrate metabolism, water and electrolyte balance Demands on the cardiovascular and respiratory systems increase

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Headaches in Children

Causes

Many possible factors including tension, braces, infection, accidents, imbalance or weakness of eye muscles Headache diary, biofeedback, progressive muscle relaxation

Interventions

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Recurrent Abdominal Pain (RAP)

Defined as pain that occurs at least once per month for 3 consecutive months, accompanied by pain-free periods, and is severe enough to interfere with a childs normal activities Incidence/Causes

Only 10% of children with RAP have identifiable organic cause; others have psychosocial/psychological causes
Stress mgmt, cognitive-behavioral, operant theory modalities Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48

Interventions

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Pain in Children with Sickle Cell Disease

Opioids are considered the major therapy and are started in early childhood and continued throughout adult life Nonpharmacologic interventions Goals of treatment of acute episodes

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Pain Management for Childhood Cancers

Sources/types of pain

Examples include infection, neuropathy, chemotherapy, operative

Interventions Obstacles to successful analgesia

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Pain and Sedation at End of Life

Goals of treatment

Comfort, relief of suffering Relieve suffering when there is no feasible or acceptable means of providing analgesia that preserves alertness

Use of continuous sedation for control of pain

Parents need reassurance that opioids are treating pain and not causing childs death and that the childs advancing disease is the cause of death
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