1. Pediatric Pain Assessment
Monique Sandoval
Azusa Pacific University
Scientific Writing
GNRS 507
Specifically children 36 months of age and younger, defined as “preverbal”

2. Background
The Joint Commission on Accreditation of Healthcare Organization (JCAHO) requires effective pain assessment & management within accredited healthcare institutions
Pain is subjective
Inappropriate assessment tool utilization
FACES vs. FLACC scale
(Vael & Whitted, 2014)
This specific age group cannot verbally, fully describe their pain, leaving them at risk for prolonged or unrecognized pain
FACES – OLDER THAN 36 MONTHS OF AGE
FLACC – YOUNGER THAN 36 MONTHS OF AGE
GOLD STANDARD IS PT SELF REPORT BUT IN OUR CASE THIS IS NOT AN OPTION
FLACC SCALE CATEGORIES: FACE, LEGS, ACITVITY, CRY, CONSOLABILITY ZERO TO 2 IN TERMS OF NO PAIN OR DISTRESS PROGRESSING TO SIGNS OF PAIN AND DISTRESS

3. PICOT Question
In hospitalized pediatric patients younger than 36 months of age, does an educational intervention intended to educate staff nurses about the use of an appropriate pain assessment scale alter nursing practice by increasing pain assessment, and decreasing pain, in preverbal children over a period of two months, compared to no educational intervention?

4. Key Points Nurse education in-services demonstrate positive outcomes
Developmentally & age appropriate pain assessment tools, such as the faces, legs, activity, cry, consolability (FLACC) scale
Increased nurse awareness
Increased pain management
Decreased pain
(Treadwell, Franck, & Vichinsky, 2002; Vael & Whitted, 2014)

5. (Fineout-Overholt, Melnyk, Stillwell & Williamson, 2010)
Grading Outcome
Eight studies were included demonstrating reliable evidence upon critical evaluation
Majority were graded as level 3
One was graded as level 4 and another as level 6, according to Fineout-Overholt, Melnyk, Stillwell, and Williamson (2010) Hierarchy of Evidence for Intervention Studies criteria
(Fineout-Overholt, Melnyk, Stillwell & Williamson, 2010)
The articles demonstrated reliable evidence and were critically evaluated and graded as a majority of level 3 evidence, controlled trials without randomization.
One of the articles was graded as a level 4 & another a level 6,
according to the grading criteria utilized
Fineout-Overholt, Melnyk, Stillwell, and Williamson (2010) Hierarchy of Evidence for Intervention Studies criteria.

6. Clinical Implications
Implementation of quarterly in-service pediatric nurse education per unit
Discussion topic: developmentally & age appropriate pain assessment tools (FLACC) for the preverbal patient population
FLACC scale: effective, convenient, safe and easily implemented intervention to appropriately assess pain in preverbal pediatric patients
(Vael & Whitted, 2014)
The plan:
Quarterly In-service nurse education will be implemented
is a cost-effective intervention that can be implemented in virtually any hospital unit setting
Lead by charge nurses per unit
Discussion: developmentally & age appropriate pain assessment tools (FLACC) for the preverbal patient population

7. Potential Barriers Staff response to change Attitude & unwillingness
Loss of independence
Post intervention, pediatric nurses reported increased FLACC scale use, increased pain assessment, improved staff responsiveness to pain, as well as greater satisfaction with assessment tools
(Treadwell, Franck, & Vichinsky, 2002; Vael & Whitted, 2014)
Another barrier: Lack of adherence once implemented
We need adherence criteria in terms of further policy development or amendment to policy stating specific adherence criteria hospital must maintain

8. Ethical Considerations
To comply with patient rights & justice frameworks, assessment of pain in all patients is required by JCAHO
Ethical concern for any patient if needs are not met during one’s hospital stay
Pain is physical, emotional, and spiritual for many patients, and every patient has the right to have their pain assessed & managed to provide quality, personalized, patient-centered care (O’Brien, 2014)
Justice – decency to provide quality care which means assessing and managing pts pain
Beneficence – non-maleficence
in order to do good by our pts and prevent we must obtain baseline data so we know the tolerance and levels of pain to treat pain adequately to keep our pts comfortable
if the pt can’t speak for themselves then it is our duty as that pts advocate to assess pain and treat accordingly

9. Expected Outcomes
Increased assessment, documentation & management of pain
Decreased pain
Increased nurse awareness
(Vael & Whitted, 2014)

10. Modes of Measurement Documentation of pain assessment Patient charts
Decreased pain after assessment & treatment
Scores in the documented categories of face, legs, activity, cry, and consolability, within patient charts, will be evaluated to measure pain assessment and management post-intervention (Vael & Whitted, 2014).
How will we measure this?
Pain assessment will be documented in the pt chart and we will measure the decreased pain per category documented by using the FLACC scale
FLACC – ranges from 0 to 2, each category
Faces, legs, activity, cry, consolability from 0 to 2 progressing from no signs of pain, to signs of pain and distress, per category

11. Conclusion Nurse education is cost-effective
Easily implementable intervention
Increases nurse awareness
(Vael & Whitted, 2014)
Improves assessment & reduces pain in preverbal pediatric patients

12. Reference
Baulch, I. (2010). Assessment and management of pain in the paediatric patient. Nursing Standard, 25(10), Retrieved from b2e39f39c69%40sessionmgr4005&vid=1&hid=4102
Bear, L., & Ward-Smith, P. (2006). Interrater reliability of the COMFORT scale. Pediatric Nursing, 32(5), 427. Retrieved from e2d383a7c0a0%40sessionmgr4004&vid=0&hid=4202&bdata=JnNpdGU9ZWRzLWxpd mU%3d#db=rzh&AN=
Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., Williamson, K.M. (2010). Critical appraisal of the evidence: Part I. AJN, 110(7). 47–52.
Johansson, M., & Kokinsky, E. (2009). The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care. Nursing In Critical Care, 14(3), doi: /j x
O'Brien, M. (2014). The nurse-patient relationship: A caring ministry. In Spirituality in nursing standing on holy ground (5th ed., pp ). Burlington, MA: Jones and Bartlett Pub.

13. Reference
Pain management for children. (2001, April 1). Retrieved March 20, 2015, from health_info/your_health_first/kids/pain.cfm
Smyth, W., Toombes, J., & Usher, K. (2011). Children's postoperative pro re nata (PRN) analgesia: Nurses' administration practices. Contemporary Nurse: A Journal For The Australian Nursing Profession, 37(2), doi: /conu
Stanley, M., & Pollard, D. (2013). Relationship between knowledge, attitudes, and self-efficacy of nurses in the management of pediatric pain. Pediatric Nursing, 39(4), Retrieved from d3f2a124db30%40sessionmgr4004&vid=1&hid=4102
Treadwell, M., Franck, L., & Vichinsky, E. (2002). Using quality improvement strategies to enhance pediatric pain assessment. International Journal for Quality in Health Care, 14(1), doi: dx.doi.org.patris.apu.edu/ /intqhc/
Vael, A., & Whitted, K. (2014). An educational intervention to improve pain assessment in preverbal children. Pediatric Nursing, 40(6), Retrieved from dd08e4c63e%40sessionmgr4004&vid=1&hid=4102

14. Reference
Van Hulle Vincent, C., Wilkie, D., & Wang, E. (2011). Pediatric nurses' beliefs and pain management practices: an intervention pilot. Western Journal of Nursing Research, 33(6), doi: