2Acute Pain- the History ! Before no formal research looking at pain management in childrenSwafford 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
3Do children feel pain? Pain fibers present at end of 2nd trimester Increased heel sensitivity post heel sticksCrying increases for days post circumcision6 month olds-anticipate and avoid pain
4What is Pain?“Pain is whatever the experiencing person says it is, existing whenever they say it does”(McCaffery and Pasero, 1999)
5What 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.)
6What 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.
7What 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.)
8Let’s review what is Pain Pain is a signal,nothing more,nothing lessALL PAIN IS REALPAIN is PAIN,Suffering is Optional!
9Pathophysiology of Pain Acute vs Chronic PainWhat is Acute Pain?brief duration: usually less than 3 monthsIdentifiable cause / injury / surgery or diseasepredictable endsubsides with healing
10Pathophysiology of Pain Acute vs ChronicWhat is chronic pain?Peristent pain lasting longer than 6 months that is generally associated with a prolonged disease process
11Pathophysiology of Pain NociceptorsFree nerve endings at site of tissue damagePurpose of nociceptors are to transmit pain impulses along specialized nerve fibers,the A-delta and C-fibers, to the dorsal horn of the spinal cordSubstantial gelatinosa, aka “gate-keeper”Regulates transmission of pain and other nerve impulses to the CNSLocated in the dorsal horn of s.c.
13Pathophysiology of Pain BrainOnce 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
14Pathophysiology of Pain ANSActivated in response to painTachycardiaPeripheral vasoconstrictionDiaphoresisPupil dilationIncreased secretion of catecholamines and adrenocorticoid hormones
15Pathophysiology of Pain Gate Control TheorySince pain and non-pain impulses are sent along the same pathways, non-pain impulses can compete with pain impulses for transmission
16Types of PainNociceptive: stimuli from somatic and visceral structuressomatic: sharp/stinging; superficial - dermal or epidermal layers; deep- bones or deeper structuresvisceral: abdominal organs, peritoneum and pleuraNeuropathic: stimuli abnormally processed by the nervous systemdamage to a nerve - infiltration, compression or infection
17Types of Pain Somatic Sharp, hot, stinging Generally well localized Associated with local and surrounding tenderness
18Types of Pain Visceral Dull, cramping, colicky, often poorly localized Tenderness locally or in the area of referred painAssociated with symptoms such as nausea, sweating and cardiovascular changes
19Types of Pain Neuropathic Dysaesthesia (unpleasant abnormal Pain descriptors – burning, shooting and stabbingDysaesthesia (unpleasant abnormalsensations)Hyperalgesia (increase response to a normally painful stimulus)Allodynia (pain due to a stimulus that does not normally evoke pain eg. light touch)
20Physiological consequence of Pain Affects multiple body systems(refer to table 18-1)Respiratory ChangesRespiratory AlkalosisDecreased O2 satsRetention of secretions
21Physiologic Consequences of Pain NeurologicalIncrease in HR, blood sugar, cortisol levels, and intracranial pressure (risk for IVH)Metabolic effectsIncrease in fluid and electrolyte lossesImmune SystemIncreased risk of infectionGastrointestinalImpaired functioning
22Behavioral Indicators of Pain Restlessness and agitated or hyper-alert stateShort attention spanIrritabilityFacial grimacing, posturing, guardingAnorexiaLethargySleep disturbanceAggression
23Assessing Pain in Children Behavioral Responses and Verbal Descriptions of Pain by Children of Different Developmental StagesRefer to Table 18-4Children’s Understanding of Pain by Developmental StagesRefer to Table 18-3
24Myths and Misconceptions around Pain Active children cannot be in painGenerally there is a “usual” amount of pain associated with any given procedureIf children are asleep then they are pain freeGiving narcotics to children is addictive and dangerousNarcotics always depress respiration in childrenInfants don’t feel painThe less analgesia administered to children the better it is for them
25Why is Pain Assessment Important? Provides an avenue for more effective management of painPromotes communication between the child, parents and health professionalsSupports evidence based practiceProvides continuity through the hospitalAllows children to indicate the intensity of their pain
26Challenges with Assessing Children ! Lower levels of verbal fluency / non-verbal childrenMay not verbally communicate presence of pain unless specifically askedPain highly individualizedParents often called upon to provide pain ratings - can be different to patients perspective
27Criteria For Selecting A Pain Tool Established as valid and reliableDevelopmentally appropriateEasily and quickly understoodLiked by patients, families and cliniciansInexpensiveAppropriate for different languages and culture
28The Questt Tool Question the child Use pain rating tools Evaluate behavior and physiological changesSecure parents involvementTake the cause of pain into accountTake action and evaluate the results
29Pain Assessment Tools Newborn/ Infant: CRIES Developed for use in preterm and ft infants in ICUMeasures crying, O2 sat, HR, BP, expression and sleeplessnessNeonatal Infant Pain Scale (NIPS)Evaluates facial expression, cry, breathing, arms, legs and state of arousalPremature 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
30CRIES neonatal postoperative Pain Scale Refer to table 18-5
31NIPS Scale Refer to table 18-6 Recommended for children under 1 year old.A score of 3 or more= pain
32Pain Assessment Tools Toddler Preschooler FLACC Oucher Faces pain-rating scalePreschoolerFaces Pain-rating Scale (usually 3 and over)Acronym for face, legs, cry and consolabilityBody Outline (3 and over)
38Numeric 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)
39Assessing Readiness for Use of Pain Scales Refer to Box 18-3Assess a chlid’s language, and understanding of conceptsChildren 2-3 years-oldUnderstand more or lessNo more than 3 choices on pain scaleOnly 26% of 5 year olds understand numeric scaleWhich number is smaller 4 or 7?
40Children with Cognitive Impairment Assessment of pain difficultContribute to inadequate analgesiaMerkel et al (1997)FLACC scale validated for cognitively impaired children
41Case StudyTom 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?
42InterventionPharmacologic and Non-pharmacologic methods of pain control
44Pharmacologic Pain Control OpioidsEx: morphine, codeineOften for severe painRefer to p 575 for recommended drug dosages and table 18-8, p 577 for S/Sx of Opioid withdrawalNaloxone is the reversal agent used for opioid adverse effects (hypotension, respiratory depression)
45Pharmacologic Pain Control NSAIDs and Non-opioid analgesicsEx of NSAIDS= aspirin, Ibuprofen, NaproxenEx of Non-opioid analgesics= acetaminophenMost commonly used for bone, inflammatory, and connective tissue conditionsNSAIDs and opioids can be used in comboRemember the differences b/t NSAIDs and acetaminophen!Refer to p 576 for drug dosages
46Nursing Considerations when administering a Pain analgesic Always document pain level pre and post medication administrationAlso document any other nursing interventions and if they were useful
47Patient 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 childChildren 5 years and olderChildren should be able to push the button and understand that this will give them pain relief.
48Non-pharmacologic Methods of Pain Control DistractionHypnosisImageryRelaxationComfort measuresQuiet presenceMusic massageHeat/coldBathsvibrations
49Complimentary Therapies for Pain Control Refer to p 579 in textSucrose solutionMuscle relaxation techniquesBreathing techniquesElectroanalgesiaBiofeedbackAcupucture
50Pediatric Considerations in Disaster Preparedness Impact of disasterPsychologicalGeneral effectsAnxietyStressfear
51Pediatric Considerations in Disaster Preparedness Impact of DisasterDevelopmental considerationsToddler/ preschoolerSchool ageAdolescentResponses to Disasters by Children of Different Age GroupsRefer to Table 16-2 (p 523)
52Pediatric Considerations in Disaster Preparedness Pediatric drugs/ suppliesAdvanced planningMedically fragile in communityCommunity disaster response systemsFamilyResource packageAnticipatory Guidance