Pediatric Pain Management: Issues & trends Sherry Nolan, RN,MSN 2009

Historical Perspective  Misconceptions about pain in children  Taxonomy  Case Study  4 Components of the Pain Experience

Myth: CNS is Immature in kids so they don’t feel pain as much  Fact: All structures are in place for the transmission of pain by the 30th week of gestation.  Fact: substance P (neurotransmitter for pain) -16 wks; cutaneous sensory receptors - 20 wks; synaptic connections -24 wks; nociceptive nerve tracts completely myelinated-30 wks

Taxonomy  Nociception  Plasticity  Gate Control Theory  Addiction  Physical Dependence  Chronic pain  Acute pain  Expansion of Receptive field size  Sleeping nociceptors  Sensitization

Nociception  “the activity produced in the nervous system by potentially tissue-damaging stimuli” OR * “the activation of nerve axons by thermal, chemical or mechanical energy sufficient to threaten the integrity of the cell”

Plasticity  Different responses to the same stimulus, presumably as a result of different environmental & psychological factors that can moderate the signals initiated by noxious stimuli & thereby change the individual’s perception & experience of pain  The younger the organism, the greater the plasticity!

Gate Control Theory  Ascending & descending pain- suppressing or pain- enhancing systems are activated by situational factors

Active children cannot be in pain  “Play is the work of children”

It is unsafe to administer opioids to children as they become addicted

Physical Dependence  A physiological state in which the body develops a need for the opioid drug in order to maintain equilibrium. Manifested by a drug-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, &/or administration of an antagonist. Does NOT = addiction.

Addiction  Refers to overwhelming preoccupation with obtaining and using a drug for its’ psychic effects, not for pain relief  Include one or more of the following:impaired control over drug use, compulsive use, continued use despite harm, and craving (4 Cs)

EQUIANALGESIA Refers to the fact that, when substituting one drug for another, use an equianalgesic chart so that the pain-relieving effects of the new drug will deliver the same response.

Overwhelmingness of the Pain Experience  Physiological disequilibrium  Behavioral disorganization  Long term consequences of under-treated pain  Overall stress response

Children will always tell if they have pain

Narcotics Always depress respirations in kids  Pain is a potent respiratory stimulant  Respiratory tolerance escalates along with the need for medication  Sedation level check very important

The best way to administer analgesia is by injection- not!  IV bolus gives a predictable peak action & duration of action.  IVCD provides a steady blood level without peaks & valleys with their accompanying SEs.

Infants & children don’t remember pain  Remembered pain & currently experienced pain are different  Infant with heel stick  Aversion/anticipatory vomiting

Children can’t tell you where they have pain  Good assessment skills are the cornerstone of adequate pain management

4 components of pain  Nociception  Pain  Suffering  Pain behaviors nociception pain suffering Pain behaviors

Definition of pain  “Pain is whatever the experiencing person says it is, existing wherever and whenever he or she says it does.” ( McCaffery )  Chronic Pain: Pain that has outlived it’s usefulness  Acute Pain: An adaptive, beneficial response necessary for the preservation of tissue integrity

Topicals  ANE-cream (no- scream Cream)/proper application  Pain-Ease  New trials coming up, new products; zingo, synera,etc  Sweet-ease-new P&P

TJC standards  Recognize the right of pts. to appropriate assessment & management of pain.  Screen for existence, nature & intensity of pain.  Make pain management a priority  Perform a comprehensive pain assessment; if pain is present, include location, quality, onset, frequency & intensity  Record results of assessment in a way that facilitates regular re- assessment & follow-up.  Determine & ensure staff competency in pain assessment & manage- ment. Address competency in orientation & continuing education.  Establish P&Ps that support attentive & aggressive pain management

TJC standards (cont’d)  Educate pts & families about importance of effective pain management.  Promise pts. effective pain relief upon admission.  Remember, while TJC accredits health care organizations, it is individual healthcare providers who manage pain.  Address pt needs for symptom management in discharge planning.  Include pt. outcomes in measuring effectiveness of pain assessment & management.

Ethical Considerations As nurses we are bound morally and legally to act as patient advocates. Thus, not to do good (beneficence=relieving pain), avoid harmful conditions (non-maleficience), or include pts in their own plan of care (respect for autonomy) is clearly unethical behavior.

placebos Don’t order, don’t give

Steps to take  Believe the patient!!!  Preventive approach is best.Rethink the meaning of prn>ATC  Treat anxiety & teach colleagues;empower & teach parents & pts about pain & rx  Involve pts/parents in the plan of care; initiate standardized MPC if pt. c/o pain  Use equianalgesia charts  Use a combination of strategies, pharmacological & non- pharmacological.  Don’t forget palliative care team!  Make a commitment to be aware of current trends in assessment & treatment of pain in children.  Make pain management a priority.

You be the one to say:  The pain Stops here!!!!!!!!!