1. Pain Management Lesley Foster EB Nurse Clinical Nurse Specialist, (Paediatric) DebRA UK Patients’ photographs have been removed from this presentation

2. Pain management Start early 2 days old. Oromorph and paracetamol prior to dressing changes

3. Acute Pain from Bullae / Wounds Give prescribed analgesia Prepare dressings Lance blisters to prevent from enlarging. Use Cryogesic spray (Ethyl Chloride) if pain / anticipatory fear Select atraumatic dressing Use silicone medical adhesive remover spray (Appeel) if adherence has occurred

4. Use a Pain Assessment Tool Patient focused Individual Cultural / social Assess and formulate a baseline pain score Use a recognised tool Behavioural characteristics Physiologically induced changes

7. Non Pharmalogical Therapies Visualisation Guided imagery

8. Guided Imagery A therapeutic technique that allows two people to communicate on a reality that one of them has chosen to construe through an altered state of consciousness and achieved in the process of imaging. BH Whitaker

9. Pain Management Mild Pain – combine simple analgesia with a non steroidal e.g. paracetamol with ibuprofen Severe pain – Opioid analgesia and anxiolytic sedation e.g. midazolam Fentanyl lozenges. Entonnox (occasional use) Chronic background pain – may require long acting morphine (MST) Fentanyl patches (Appeel for safe removal) Neuropathic pain – may respond to low dose amitriptylline or gabapentin

10. Peripheral opioid use 10mg of morphine sulphate in 15mg Intrasite gel with dressing changes (0.2mg/kg of morphine) Concentration may be increased for optimal effect Peripheral opioids in inflammatory pain Archives of Disease in Childhood 2004;89:679-681 Watterson G, Howard R, Goldman A.

11. Dressings with ibuprofen? Biatain –Ibu foam dressing with ibuprofen designed to provide moist wound healing and reduce pain at the wound site. For moist wounds only. Only just available. Not licensed for those under 12 years! ?absorption – stop oral anti inflammatory drugs until further studies taken

12. The environment Child friendly Undisturbed Distraction available Close window, switch off fan Personal choice – be realistic.

13. Preparation Templates Dressings cut to size Anticipate – wound swab, adherence – Appeel spray –demonstrate before need Analgesia & / sedation given Check for stinging from products e.g. honey

14. Be realistic Don’t offer in hospital what is not available at home (e.g. entonnox) Don’t promise a product will not sting or adhere Consider schooling and time available