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

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, non-pain 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; 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

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 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)

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 / 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

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 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)

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 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 Non-pharmacologic 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 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!!