Child Health
Nursing
Partnering with
Children & Families
Jane W. Ball
Ruth C. Bindler
Chapter 18
Pain Assessment
and Management
Child Health Nursing: Partnering with Children & Families
By Jane W. Ball and Ruth C. Bindler
© 2006 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
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?
• 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?
• “Pain is whatever the experiencing
person says it is, existing whenever
they say it does”
(McCaffery and Pasero, 1999)
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?
• 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?
• 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 Pain
• Pain is a signal,
– nothing more,
– nothing less
• ALL PAIN IS REAL
• PAIN is PAIN,
• Suffering is
Optional!
Pathophysiology 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 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 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 Pain
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology 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 Pain
• ANS
– Activated in response to pain
• Tachycardia
• Peripheral vasoconstriction
• Diaphoresis
• Pupil dilation
• Increased secretion of catecholamines and
adrenocorticoid hormones
Pathophysiology of Pain
• Gate Control Theory
– Since pain and non-pain impulses are
sent along the same pathways, nonpain impulses can compete with pain
impulses for transmission
Types of Pain
• Nociceptive: stimuli from somatic
and visceral structures
– somatic: sharp/stinging; superficial dermal or epidermal layers; deepbones 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 Pain
• Somatic
– Sharp, hot, stinging
– Generally well localized
– Associated with local and surrounding
tenderness
Types 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 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
of Pain
• Affects multiple body systems
• (refer to table 18-1)
• Respiratory Changes
– Respiratory Alkalosis
– Decreased O2 sats
– Retention of secretions
Physiologic Consequences of
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 Pain
• Restlessness and agitated or hyper-alert
state
• Short attention span
• Irritability
• Facial grimacing, posturing, guarding
• Anorexia
• Lethargy
• Sleep disturbance
• Aggression
Assessing 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 Misconceptions
around 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
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
Children !
• Lower levels of verbal fluency / nonverbal 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 A
Pain 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 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 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
postoperative Pain Scale
• Refer to table 18-5
NIPS Scale
• Refer to table 18-6
• Recommended for children under 1
year old.
• A score of 3 or more= pain
Pain 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 Scale
A
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
B
C
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Faces Pain Scale
Pain Assessment Tools
• School Age
– Numeric Pain Scale (9 yrs- adult)
– Oucher
– Faces pain-relating scale
– Poker chip scale
– Work graphic
– Visual analogue
Pain Assessment Tools
• Adolescent
– Numeric Pain Scale
– Oucher
– Faces Pain-relating scale
– Poker chip
– Work graphic
– Visual analogue
– Adolescent pediatric pain tool
Numeric 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
of 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 Cognitive
Impairment
• Assessment of pain difficult
• Contribute to inadequate analgesia
• Merkel et al (1997)
– FLACC scale validated for cognitively
impaired children
Case 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?
Intervention
• Pharmacologic and Nonpharmacologic methods of pain
control
Pharmacologic Pain Control
• Pain Medications include:
– Opioids
– Nonsteroidal anti-inflammatory drugs
(NSAIDs)
– Non-narcotic analgesics
(acetaminophen)
Pharmacologic 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 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
administering 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
(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
of Pain Control
•
•
•
•
•
Distraction
Hypnosis
Imagery
Relaxation
Comfort measures
–
–
–
–
–
Quiet presence
Music massage
Heat/cold
Baths
vibrations
Complimentary Therapies
for Pain Control
• Refer to p 579 in text
• Sucrose solution
• Muscle relaxation techniques
• Breathing techniques
• Electroanalgesia
• Biofeedback
• Acupucture
Pediatric Considerations in
Disaster Preparedness
• Impact of disaster
– Psychological
• General effects
• Anxiety
• Stress
– fear
Pediatric Considerations in
Disaster 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
Disaster 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
too painful!!
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Care of Pain in Children - Salem State University: Salem