Pain Assessment and Management in Children Chapter 5 Pain Assessment and Management in Children

Consequences of Pain Children of All Ages Can Perceive Pain Unrelieved Pain Is a Major Stressor Physiologic Psychologic Repeated Pain in Infants Can Lead to Future Sensitivity Self-Protective Behavior Due to Pain Can Delay Healing

PAIN BEHAVIORS Acute Pain . Acute Pain Short attention span, irritability, grimacing, posturing, limb flexion, sleep disturbances, lethargy, withdrawal . * * See Box 5-1 Children’s Responses to pain at various ages, P. 153, Wong

Pain Behaviors Chronic Pain Physiologic adaptation may mask signs

Pain Scales Choose Developmentally Appropriate Scale Behavioral and self-report types Determine child’s ability to demonstrate concepts of degree, rank order, estimation, and classification

Behavioral Pain Scales CRIES (p. 160, Wong) Crying, Requires O2, Increased vital signs, Expression, Sleeplessness FLACC (p. 159, Wong) Face, Legs, Activity, Cry, Consolability NIPS (Neonatal Infant Pain Scale) (p. 159, Wong) Expression, cry, breathing, arm and leg movements, arousal state

Table 15-5 FLACC Behavioral Pain Assessment Scale

Self-Report Scales: Body Outline Faces Oucher (see next slide) Poker Chip Numeric Rating Word-Graphic Rating

Non-pharmacologic Strategies for Pediatric Pain Management List 4 non-pharamalogic strategies for pain management in the: Infant toddler/preschool school-age/adolescent ___________________ __________________ ___________________

Non-narcotic pain relief Used for relief of mild to moderate pain or chronic pain May be used in combination with opioid to effectiveness and amt. of narcotic needed Non-opioid analgesic: acetaminophen NSAIDS: Ibuprofen (available in liquid form) Naproxen (available in liquid form) Ketorolac (Toradol) see indications in text Aspirin (is not used in children <19 years old with possibility of viral illness) (See Table 5-4 Wong, p. 171)

Opioid Use: ie, morphine & hydromorphone, fentanyl Severe Pain or Injury Route: Oral, IM, IV Determine equianalgesic dose (see p.176, Table 5-8) Based on drug, child’s weight Avoid IM route if possible Monitor Effects Common: sedation, nausea, vomiting, itching, constipation, urinary retention

Opioids Often combined with a non-opioid to provide increased analgesia without increased side effects. (Ex. Tylenol No. 2 contains 15 mg codeine with 300 mg acetaminophen) Morphine is considered the gold standard for management of severe pain. Effective morphine substitutes used in pediatric client include hydromorphone (Dilaudid) and fentanyl (Sublimaze)

Opioid Risks: Respiratory Depression Unresponsive Respiratory rate less than 12 breaths per minute Cardiovascular Collapse Addiction Very rare

Define the following terms as pertaining to pediatric pain: Physical dependence Withdrawal Tolerance Over what period should children be weaned off opioids to prevent withdrawal symptoms?

Pediatric pain relief: PCA-generally used for children 7+ years old and able to press button Most useful first 48 hr. post surgery

Regional Pain Management: Local nerve block: ie, regional femoral block Epidural nerve block:

EMLA (p. 730, Ball) (Eutectic Mixture of Local Anesthetics) Combination of lidocaine 2.5% and prilocaine 2.5% in an emulsion. Apply a thick layer of cream to intact skin & cover with occlusive dressing Leave in place 1 hr. for minor procedure, 2 hrs. for major procedure.

Nonpharmacologic Methods Gate Control Theory Inhibitory neuron stimulation reduces pain sensation Can Enhance Effects of Analgesics Methods Distractions Stimulations

24% Sucrose Solution Sweet-Ease is a 24% sucrose and purified water solution which significantly reduces discomfort in the infant. It may be used in all areas where infants are seen: NICU, PICU, ER and pediatrician’s offices. Packaged in 2 convenient sizes: 2m. Vial to administer directly onto tip of infants tongue or buccal surface. 15 ml translucent, spill resistant cup which allows for dipping a pacifier into the cup.

Acute Pain: Nursing Care Assess Pain Situational factors Cognitive, behavioral, emotional Use appropriate assessment tool Partner with parents Typical reactions? Effective relief strategies?

Acute Pain: Nursing Care (cont’d) Planning and Implementation Evaluate prescribed analgesics Mg of drug per kg of body weight Drug choice for level and quality of pain Appropriateness of interval, route Nonpharmacologic methods Appropriate complementary therapies

Acute Pain: Nursing Care (cont’d) Evaluate Effectiveness of analgesics, complementary therapies Time, quality of relief Understanding by child and parents of management

Clinical Therapies: Acute Pain Analgesics and Complementary Therapies May Be Used for Acute Pain Complementary Therapies May Decrease Amount of Medication Needed for Acute Pain

Clinical Therapies: Chronic Pain Individualized Treatment Plan Focusing on Improved Function and Comfort Analgesics Often Prescribed In Combination

Clinical Therapies: Chronic Pain (cont’d) Other Medications Transdermal fentanyl patches Tricyclic antidepressants Gabapentin Exercise and Physical Therapy to Promote Improved Function Complementary Therapies

Procedure Sedation/Analgesia Before Procedure Explain expected sensations Use topical anesthetics Avoid delays During Procedure Monitor for respiratory depression Visual confirmation and pulse oximetry Check vital signs every 15 minutes

Procedure Sedation/Analgesia (cont’d) After Procedure Assess cardiovascular and respiratory function Assess arousability Assure adequate hydration Protect from injury Falls from bed, while ambulating

Summary Children of All Ages Perceive Pain Unrelieved Pain Is a Major Physiologic and Psychological Stressor Nurses Must Be Able to Assess a Child’s Pain Both Pharmacologic and Nonpharmacologic Interventions May Relieve Pain

Resources City of Hope http://www.cityofhope.org Pain/Palliative Care Resource Center Web site.

Resources (cont’d) American Pain Society www.ampainsoc.org A multidisciplinary organization of basic and clinical scientists, practicing clinicians, policy analysts, and others. The mission of the American Pain Society is to advance pain-related research, education, treatment, and professional practice.

Resources (cont’d) The International Association for the Study of Pain (IASP) www.iasp- pain.org The largest multidisciplinary international association in the field of pain. Wisconsin Pain Initiative http://aspi.wisc.edu/wpi/ The WPI is dedicated to overcoming the barriers that prevent the relief of pain. City of Hope http://www.cityofhope.org Pain/Palliative Care Resource Center Web site.