1. Chapter 7: Pain assessment and management in children
Laura Salisbury RN, MSN/Ed.

2. Pain Assessment Three types of measures to assess child’s pain:
Distress behaviors: What are these?
Developmental characteristics of pain response (see box 7-1, p. 159)
Three types of measures to assess child’s pain:
Behavioral
Physiologic
Self-report
When are these measures accurate?
What makes them inaccurate?

3. Pain rating scales for Children
FACES
FLACC
OUCHER
Poker chip tool
Word-graphic rating scale
Numeric scale
VAS (visual analog scale)
Color tool

4. Pain in Neonates Difficult to assess
Can only be based on physiologic and behavioral responses
Assessment tools:
CRIES
PIPP (Premature Infant Pain Profile)
NPASS (Neonatal Pain, Agitation, and Sedation Scale)

5. Pain in Children with Communication and Cognitive Impairment
At greater risk for under treatment of pain
Primary caregiver important source of information
Pain measurement tools:
Non-communicating Children’s Pain Checklist
PICIC (Pain Indicator for Communicatively Impaired Children)

6. what may affect cultural appropriateness of pain assessment?
Cultural issues:
what may affect cultural appropriateness of pain assessment?
Children with Chronic Illness and Complex Pain
Important components of assessment: what are they?

7. Pain Management Nonpharmacologic management Virtual reality
Containment/swaddling/tucking
Nonnutritive sucking/with or without sucrose
Kangaroo care
Complementary pain medicine

8. Pharmacologic management
Based on weight until 50 kg (110 lbs)
Acetaminophen
NSAIDS
Opioids
Adjuvants

9. Routes and Methods of Analgesic Drug Administration
Oral
PCA: Patient-controlled/nurse-parent controlled
Transmucosal
IV/Sub-Q
Intramuscular
Intranasal
Intradermal
Transdermal/topical
EMLA
LAT
Numby Stuff
Epidural/Intrathecal
Rectal
Regional nerve block
Inhalation

10. Monitoring and treatment of side effects from opioids
Respiratory depression
Constipation
Pruritis
Nausea/vomiting
Sedation
Physical dependence
Withdrawal
Tolerance
Addiction (psychologic dependence)

11. Painful and Invasive Procedures/Postoperative pain
Evaluation of therapy
Possible effects of pain in infancy/childhood
Painful and Invasive Procedures/Postoperative pain
Use of nitrous oxide
Surgery and traumatic injury generate a catabolic state
Preemptive analgesia
Multimodal analgesia

12. Recurrent headaches in children
Recurrent abdominal pain in children
Cancer pain in children
Peripheral neuropathy
End-of-life pain and sedation

13. Chapter 22: Pediatric variations of Nursing Interventions
Laura Salisbury RN, MSN/Ed.

14. Informed Consent Patient assent
When is treatment given without parental consent?

15. Preparing children for procedures
Doing the procedure
Treatment room
Be confident
Use distraction
OK to express feelings; OK to cry
After procedure: Allow venting, give positive reinforcement

16. Surgical Procedures Postoperative care Surgical Procedures
Advantages vs. disadvantages of keeping parent with child until anesthesia
Preoperative sedation: necessary?
Fasting before hand? (Table 22-1, p. 696)
Postoperative care
Symptoms of malignant hyperthermia; how is it treated?

17. General Hygiene and Care
See Skin Care guidelines,
box on p. 700
What is epidermal stripping?
How do you encourage nutrition? Fluid intake?

18. Controlling increased temperature
Fever vs. hyperthermia: what is the difference?
Fever: antipyretic FIRST, then cooling measures: don’t allow shivering
Antipyretics do not prevent febrile seizures
Hyperthermia: Antipyretics will not work
Concerning signs: See box p. 704

19. Safety Accurate identification: how? Prevent falls: how?
Infection control: KNOW BOX 22-5 p. 707: types of precautions and patients requiring them
The most critical infection control practice is:
How should pediatric patients be safely transported?

20. Restraints Behavioral: Rarely used in pediatrics
Medical-surgical: when are they used? What precautions should be taken?
Temporary restraint (procedural): what is therapeutic holding?
Mummy restraint, swaddle, jacket restraint, arm/leg restraints, elbow restraints
How are children positioned for an LP?

21. Specimen collection
Urine: how? Getting out of disposable diaper (see “FYI” p. 712)
What is suprapubic aspiration? When is it used?
Stool: How?
Blood
Out of saline lock
Arterial: do Allen test first
Infant heel puncture:
how do you do it safely?
Where to you puncture
Sputum: Nasal washing

22. Administration of Medications
Oral route: measure accurately! Do not mix meds with bottle; know when you can crush pills
Use of an oral syringe to get med into an infant
Intramuscular: use vastus lateralis in the infant; can use ventrogluteal all ages; deltoid in older children, when small amount of med (How much can be given in a single shot in each site?)
See guidelines box, p. 721

23. Administration of Medications
IV devices
Saline lock: short term
Central access:
Non-tunneled catheters
PICC lines
Rectal
Rectum needs to be empty; can be difficult to get the right dose
NG/OG/Gastrostomy: see guidelines p. 730
Eye drops: careful not to contaminate

24. Fluid Balance Maintaining fluid balance
1 gram wet diaper weight=1 mL urine
Dealing with children who are NPO/fluid restricted
Parenteral fluid
Rehydration methods

25. Site Selection
Avoid dominant hand; avoid foot/leg in children who are walking
When rapid IV access needed, can’t get IV site: Intraosseous (runs just like an IV)
Secure the site…but allow for circulation assessment distally; watch for infiltration
How do you remove tape?
What is the difference between infiltration and extravasation?

26. Oxygen Therapy Hood Nasal cannula Oxygen tent
Mask not usually tolerated
Oxygen toxicity: retina of preterm infants; lungs damaged with excessive use
What is oxygen-induced carbon dioxide narcosis?
Pulse oximetry: Change site frequently to avoid burns, necrosis

27. Respiratory treatments
Aerosol therapy
Handheld nebulizers
MDI: use a spacer
Postural drainage: what is it? When used?
Chest physical therapy: What is it? When used?

28. Artificial Ventilation
Nasotracheal intubation preferred over endotracheal when possible
Only uncuffed endotracheal tubes for children less than age 8
Always humidify air/gas being delivered directly to trachea
Tracheostomies: What do we watch for?
Suctioning: NO MORE than 5 seconds: hyperventilate with 100% oxygen pre and post; no more than 3 passes at a time; only as often as needed
What if tube is totally occluded or it comes out? What to do?

29. Alternative Feeding Gavage feeding
Flows in by gravity
Give infants something to suck on
Gastrostomy tubes (G-tubes): may flow in by gravity or be put on pump
Nasoduodenal, nasojejunal: When are these used? What tells us that it may be in the wrong place?
Always verify placement by X-ray before first use
TPN: Control risk of sepsis, watch infusion rate, assess patient’s tolerance

30. Enemas and Ostomies
Use isotonic solutions; don’t use Fleet enema (not even the pediatric Fleet…go figure!)
Particularly distressing for preschool child
Children can be taught to manage own ostomy appliance; adolescents especially disturbed by ostomy