Pain Mngmnt & Pain Scales for Children

Obstacles to Effective Pain Mngmnt

• Knowledge deficits

• Inaccuracy of pain assessment

• Insufficient awareness of pain mngmnt interventions

• Lack of confidence regarding efficacy of pain mngmnt

• Lack of communication w/ children & parents

• Personal attitudes & beliefs

Myths of Pain Mngmnt

• Neonates don’t experience pain

• Children have no memory of pain

• Children become addicted to narcotics easily

• Narcotic administration can easily cause respiratory depression

Paint Assessment Generalized

• Highly individualized

  • Subjective experience

• Many factors influence the pain experience in children

• Pain management process:

  • Assessment

  • Intervention

  • Reassessment

Pain Assessment in Neonates & Infants

• Use behavioral & physiologic indicators to assess pain

Neonates & Infants Behavioral Indicators of Pain

• Facial expression

• Body movements

• Crying

Neonates & Infants Physiologic Indicators of Pain

• Changes in:

  • HR

  • Resp. rate

  • BP

  • O2 Sats levels (Decrease)

Pain Assessment in Toddlers

• Reacts to painless procedures as intensely as painful ones

• Expect emotional upset & physical aggression or resistance

• Limited vocabularies

  • Difficult to express pain

  • Understand “oowie” or “boo-boo”

• Hallmarks of pain:

  • Fussiness

  • Irritability

  • Loud crying

Pain Assessment in Pre-Schoolers

• Magical Thinking:

  • May think that pain is a punishment for misbehaving or having bad thoughts

  • Reassure not punishment

• May withdraw & hide from a potentially painful situation

• Are able to describe the location & intensity of pain

  • Ex: “my ear hurts bad”

• May need to be coaxed to discuss their pain

  • Coaxed: Gently urge or influence or persuade

• Begin to use pain scales to assess the severity of pain

Pain Assessment in School-Age Children

• Can communicate:

  • Type

  • Location

  • Severity of pain

• Can use metaphors to describe their pain

  • Ex: “sharp as a knife”

• May guard are or have a stiff body posture

• May deny pain in an attempt to avoid further pain or to appear brave

• Begin to use the numeric pain scale

Pain Management in Adoloscents

• Concerned primarily about body image & fear losing control over their behavior

• Display fewer outward sings of pain compared to younger children

• May withdraw or have decreased motor activity;

  • Sleep

• May deny pain or refuse medications

• May ask numerous questions & can discuss strategies to help manage their pain

• 0-10 scale is generally used

Pain Assessment Tools

• Observer-rated vs. Self-report

  • Self-report starts at Preschool

• Age-appropriate

• Used consistently

Neonate/ Infant Pain Scale (0-6 months) CRIES Scale

• CRIES

• Crying

• Requires O2

• Increased VS

• Expression

• Sleeplessness

Infants, Preverbal or Non-verbal w/ developmental delay Pain Scale (FLACC Scale)

• FLACC

• Face

• Legs

• Activity

• Cry

• Consolability

• The higher the score, the higher the pain

Pre-Schooler Pain Scale (Wong-Baker Faces Pain Scale)

• May point to the faces

• 0-5

School-Age Pain Assessment Scales (Visual Analog or NRS)

• Visual Analog Scale or Numeric Rating Scale (NRS)

• Visual Analog Scale:

  • 7-18 years

• Numeric Rating Scale:

  • NRS

  • 9 years & older

• Adult scale ask patient to rate pain 0-10

Interpreting Pain Assessment Scales

• 0 =

  • No pain

• 1-3 =

  • Mild pain

• 4-6 =

  • Moderate pain

• 7-10 =

  • Severe pain

Pain Management Guide for Children

• Multimodal & individualized interventions

• Quiet, calm environment

• Nonpharmacologic & pharmacologic approaches

• Nonpharmacologic interventions should be considered “in addition to” medication administration

• Educate child & family about pain interventions & management

• Parents can be a resource for assessing what works!

Nonpharmacologic Interventions

• Behavioral-cognitive strategies

• Biophysical Interventions

• Techniques for neonates & infants

Behavioral-Cognitive Strategies (Nonpharmacologic Interventions)

• Distraction

• Relaxation/ controlled breathing

• Guided imagery

Biophysical Interventions (Nonpharmacologic Interventions)

• Heat & cold applications (NEED order)

• Massage & pressure

Techniques for Neonates & Infants (Nonpharmacologic Interventions)

• Oral sucrose

• Breastfeeding

• Non-nutritive sucking

• Kangaroo care

  • Skin-to-skin

• Holding/ rocking

• Swaddling

Pharmacologic Interventions

• Non-opioid analgesics

• Opioid analgesics

• Topical anesthetics

Non-Opioid Analgesics (Pharmacologic Interventions)

• Used to treat mild to moderate pain

• Route:

  • PO

  • Rectal

  • IV

• Acetaminophen (Tylenol):

  • Always safe

• NSAIDs:

  • Ibuprofen, Naproxen, Ketorolac

  • Used in infants & children > 6 months of age

• NO aspirin in children

• Reassess pain after admin.

Opioid Analgesics (Pharmacologic Interventions)

• Used to treat moderate to severe pain, chronic pain

• Route:

  • Oral

  • Rectal

  • IM

  • IV

  • Transdermal

• Ex:

  • Morphine, fentanyl, hydrocodone, hydromorphone, oxycodone, & methadone

• Side effects:

  • CNS depression

  • Resp. depression

  • N/V

  • Constipation

  • Pruritic (Predose w/ Benadryl)

• Patient Controlled Analgesia (PCA):

  • Effective way to give opioids

  • Max dose limit

  • Prevents overdose (Time limit between doses)

• Reversal Agent:

  • Naloxone (Narcan)

  • Should be readily available

Topical Anesthetics

• Fast-acting

• Long-acting

Fast-Acting (Topical Anesthetics)

• Needle-free powder lidocaine (J-tip)

  • 1-3 minutes

  • Puff on medication onto the skin

• Vapocoolant

  • Anesthetic time is only 1-2 minutes

• Injectable lidocaine

Long-Acting (Topical Anesthetics)

• Preplanned

• EMLA (Lidocaine & Prilocaine):

  • Used for non-emergent procedures

  • Minimal risk of adverse effects

  • Must be applied 60-90 mins prior to procedure

  • Has to be on the skin

  • Must be applied prior to scheduled things (Several injections, IV start, etc.)

Nurse’s Role in Pharmacologic Pain Mngmnt.

• Adhering to the rights of medication admin.

• Knowledge about the drug’s pharmacokinetics & pharmacodynamics

• Assessment is crucial & ongoing

• Mon. physiologic parameters:

  • LOC

  • Resp. rate

  • O2 saturation levels

• Teach the child & parents about medication:

  • Medication freq.

  • Expected effects

  • Potential side effects