Pediatric Pain Management Presented by: Danyel Dorn RN, MSN, CPN, Clinical Nurse Educator-Pediatric Service Line

The Joint Commission mandates that all individuals have the right to effective pain/symptom management. This mandate must be included in the delivery of basic clinical nursing care. The Agency for Healthcare Research and Quality asserts that institutions have the responsibility for pain management and that this responsibility begins with the affirmation that patients should have access to the best level of pain relief that may be safely provided. Purpose

Neonates, infants, young children, critically ill and postanesthetic patients are at a higher risk for increased pain related to their inability to communicate effectively. It is essential that perianesthesia registered nurses caring for pediatric patients develop competency and expertise in assessment and management of pain in children. Purpose

The perianesthesia registered nurse will be able to perform safe, individualized pharmacologic and non-pharmacologic pain interventions with pediatric patients in perianesthesia settings using “skills of assessment, evaluation and decision-making.” Competency Statement

Criteria Key elements of a comprehensive pediatric pain assessment Preoperative pain assessment Parent description of how patient expresses pain, words his/her child uses to express pain and anxiety Behavioral observation Current pain location, intensity, description (age appropriate) Reassessment after interventions Type of measurement scale used (FLACC, Numeric, FACES) Criteria

Pharmacologic Pain Interventions Normal dosages for the pediatric patient vary according to weight; therefore, doses can be constantly changing dependent upon the size and age of the child. The volume of smaller doses leaves very little room for error. Pharmacologic Pain Interventions

Nonopiod/NSAIDS Analgesics Acetaminophen: given by mouth (PO), rectally (PR), intravenously (IV) Serum concentration peaks 60 minutes after administration Can be effective when given preoperatively for short procedures (myringotomy, ear tube placement) NSAIDS-Ibuprofen: given orally, ketorolac is given IV Nonopiod/NSAIDS Analgesics

Fentanyl: given IV in intermittent doses, should be titrated to appropriate analgesic effects to minimize adverse effects Fentanyl can be given via IV, Epidural, PCA, Intranasal Morphine: given IV, ordered intermittent doses, titrated to comfort Can be given continuous IV, epidural infusion, PCA Opioid Analgesics

Hydromorphone: given IV in intermittent doses and should be titrated to appropriate analgesic effects, while minimizing adverse effects May be given continuous IV, epidural, PCA Oxycodone/acetaminophen: PO Hydrocodone/acetaminophen: PO Opioid Analgesics

Opioid Adjuncts Clonidine: IV, continuous epidural infusion Precedex (dexmedetomidine): co- administration with anesthetics, sedatives, hypnotics and opioids Can enhance the pharmacodynamic effects of these agents Opioid Adjuncts

Multi-modal Pain Management The process of combining pharmacologic, cognitive behavioral and physical approaches to pain management Utilizing opioid and non-opioid medication therapies, to maximize pain control while minimizing opioid related side effects Utilization of heat, ice and/or positioning to promote comfort Promoting wake/sleep cycles to promote rest to assist children with coping skills Utilization of child life therapy to assist with coping mechanisms Multi-modal Pain Management

Codeine/acetaminophen: codeine is no longer recommended by the FDA due to its unstable metabolism In August 2012, the FDA warned the public that this danger exists for children who are “ultra-rapid metabolizers” of codeine, meaning that their liver converts codeine to morphine in higher than normal amounts Patient response to medications should be assessed, documented and pain assessment repeated according to institutional policy Warning

Dosing Charts

Dosing Charts

Non-pharmacologic Pain Interventions Infants and neonates: nonnutritive sucking, swaddling, reduction of external stimuli, skin to skin contact, oral sucrose, and breastfeeding. Children: position for comfort, thermal measures, distraction (play activities, TV, music), relaxation techniques, reduced lighting, massage and family presence. Non-pharmacologic Pain Interventions

Non-pharmacologic Pain Interventions Adolescents: Position for patient comfort, thermal measures, distraction, phone movies/TV music, imagery, relaxation techniques, reduced lighting, massage, allowing control of environment, deciding when family can visit, maintain modesty and privacy to help decrease anxiety, family friend (boyfriend/girlfriend) presence and participation. Non-pharmacologic Pain Interventions

Medication Administration Utilize two patient identifiers when double checking medication and confirming it is the correct patient Confirm correct order for analgesia Confirm dose and patient weight Implement weight based dose calculations: dosing is generally in mg/kg per doses Double check medication with another nurse per institution protocol – patient identification, weight, allergies, medication name, dose ordered, visual of both the container or package the medication came from as well as the drawn up medication to allow confirmation by the verifying nurse for each dose given. Medication Administration

Medication Administration Discuss pain management options with parents Parents need education about how to give medication, what to expect, various side effects and reassurance that opioid pain medication is safe for pediatric patients when dosed correctly Discuss the role of family in pediatric pain control Encourage parents to remain calm to promote decrease anxiety for child Medication Administration

Medication Administration Instruct the parents to not continually ask the child, “are you in pain?” but watch activities and medicate appropriately as directed Teach the parents to follow the medication directions and discharge instructions Inform the parents who to contact if they are concerned there is additional pain Do not tell children, “This is candy” Tell the patient it is medication and he/she needs to take it to help them feel better Medication Administration

Medication Administration Never as a child, “Are you ready for your medicine?” or “Do you want your medicine?” This is not the choice. The choice is, “Do you want me to give it to you or do you want mommy/caregiver to give it to you?” Explain that some medications do not taste good, but it is still important to take it. Children respond well to honesty and being ready to expect certain things. Have a popsicle or juice ready to get rid of the taste of the medicine Do not put medication into a cup or bottle of formula or other liquid. The nurse and the parent need to be aware of the exact dose of medication being administered Medication Administration

ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting. Reference

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