1. Child Health Nursing Partnering with Children & Families
Jane W. Ball Ruth C. Bindler
Chapter 18
Pain Assessment and Management
© 2006 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Child Health Nursing: Partnering with Children & Families
By Jane W. Ball and Ruth C. Bindler

2. Acute Pain- the History !
Before 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

3. 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

4. What is Pain?
“Pain is whatever the experiencing person says it is, existing whenever they say it does”
(McCaffery and Pasero, 1999)

5. 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.)

6. 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.

7. 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.)

8. Let’s review what is Pain
Pain is a signal,
nothing more,
nothing less
ALL PAIN IS REAL
PAIN is PAIN,
Suffering is Optional!

9. 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

10. 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

11. 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.

12. 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 All rights reserved.

13. 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

14. Pathophysiology of Pain
ANS
Activated in response to pain
Tachycardia
Peripheral vasoconstriction
Diaphoresis
Pupil dilation
Increased secretion of catecholamines and adrenocorticoid hormones

15. Pathophysiology 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

16. Types 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

17. Types of Pain Somatic Sharp, hot, stinging Generally well localized
Associated with local and surrounding tenderness

18. 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

19. Types of Pain Neuropathic Dysaesthesia (unpleasant abnormal
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)

20. Physiological consequence of Pain
Affects multiple body systems
(refer to table 18-1)
Respiratory Changes
Respiratory Alkalosis
Decreased O2 sats
Retention of secretions

21. 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

22. Behavioral Indicators of Pain
Restlessness and agitated or hyper-alert state
Short attention span
Irritability
Facial grimacing, posturing, guarding
Anorexia
Lethargy
Sleep disturbance
Aggression

23. 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

24. 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

25. 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

26. Challenges with Assessing 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

27. 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

28. 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

29. 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

30. CRIES neonatal postoperative Pain Scale
Refer to table 18-5

31. NIPS Scale Refer to table 18-6
Recommended for children under 1 year old.
A score of 3 or more= pain

32. Pain Assessment Tools Toddler Preschooler FLACC Oucher
Faces pain-rating scale
Preschooler
Faces Pain-rating Scale (usually 3 and over)
Acronym for face, legs, cry and consolability
Body Outline (3 and over)

34. Oucher Pain Scale A B C
Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

35. Faces Pain Scale

36. Pain Assessment Tools School Age Numeric Pain Scale (9 yrs- adult)
Oucher
Faces pain-relating scale
Poker chip scale
Work graphic
Visual analogue

37. Pain Assessment Tools Adolescent Numeric Pain Scale Oucher
Faces Pain-relating scale
Poker chip
Work graphic
Visual analogue
Adolescent pediatric pain tool

38. 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)

39. 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?

40. Children with Cognitive Impairment
Assessment of pain difficult
Contribute to inadequate analgesia
Merkel et al (1997)
FLACC scale validated for cognitively impaired children

41. 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?

42. Intervention
Pharmacologic and Non-pharmacologic methods of pain control

43. Pharmacologic Pain Control
Pain Medications include:
Opioids
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Non-narcotic analgesics (acetaminophen)

44. 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)

45. 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

46. 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

47. 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.

48. Non-pharmacologic Methods of Pain Control
Distraction
Hypnosis
Imagery
Relaxation
Comfort measures
Quiet presence
Music massage
Heat/cold
Baths
vibrations

49. Complimentary Therapies for Pain Control
Refer to p 579 in text
Sucrose solution
Muscle relaxation techniques
Breathing techniques
Electroanalgesia
Biofeedback
Acupucture

50. Pediatric Considerations in Disaster Preparedness
Impact of disaster
Psychological
General effects
Anxiety
Stress
fear

51. 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)

52. Pediatric Considerations in Disaster Preparedness
Pediatric drugs/ supplies
Advanced planning
Medically fragile in community
Community disaster response systems
Family
Resource package
Anticipatory Guidance

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