Pediatric Pain Assessment Monique Sandoval Azusa Pacific University Scientific Writing GNRS 507 Specifically children 36 months of age and younger, defined as “preverbal”

Background The Joint Commission on Accreditation of Healthcare Organization (JCAHO) requires effective pain assessment & management within accredited healthcare institutions Pain is subjective Inappropriate assessment tool utilization FACES vs. FLACC scale (Vael & Whitted, 2014) This specific age group cannot verbally, fully describe their pain, leaving them at risk for prolonged or unrecognized pain FACES – OLDER THAN 36 MONTHS OF AGE FLACC – YOUNGER THAN 36 MONTHS OF AGE GOLD STANDARD IS PT SELF REPORT BUT IN OUR CASE THIS IS NOT AN OPTION FLACC SCALE CATEGORIES: FACE, LEGS, ACITVITY, CRY, CONSOLABILITY ZERO TO 2 IN TERMS OF NO PAIN OR DISTRESS PROGRESSING TO SIGNS OF PAIN AND DISTRESS

PICOT Question In hospitalized pediatric patients younger than 36 months of age, does an educational intervention intended to educate staff nurses about the use of an appropriate pain assessment scale alter nursing practice by increasing pain assessment, and decreasing pain, in preverbal children over a period of two months, compared to no educational intervention?

Key Points Nurse education in-services demonstrate positive outcomes Developmentally & age appropriate pain assessment tools, such as the faces, legs, activity, cry, consolability (FLACC) scale Increased nurse awareness Increased pain management Decreased pain (Treadwell, Franck, & Vichinsky, 2002; Vael & Whitted, 2014)

(Fineout-Overholt, Melnyk, Stillwell & Williamson, 2010) Grading Outcome Eight studies were included demonstrating reliable evidence upon critical evaluation Majority were graded as level 3 One was graded as level 4 and another as level 6, according to Fineout-Overholt, Melnyk, Stillwell, and Williamson (2010) Hierarchy of Evidence for Intervention Studies criteria (Fineout-Overholt, Melnyk, Stillwell & Williamson, 2010) The articles demonstrated reliable evidence and were critically evaluated and graded as a majority of level 3 evidence, controlled trials without randomization. One of the articles was graded as a level 4 & another a level 6, according to the grading criteria utilized Fineout-Overholt, Melnyk, Stillwell, and Williamson (2010) Hierarchy of Evidence for Intervention Studies criteria.

Clinical Implications Implementation of quarterly in-service pediatric nurse education per unit Discussion topic: developmentally & age appropriate pain assessment tools (FLACC) for the preverbal patient population FLACC scale: effective, convenient, safe and easily implemented intervention to appropriately assess pain in preverbal pediatric patients (Vael & Whitted, 2014) The plan: Quarterly In-service nurse education will be implemented is a cost-effective intervention that can be implemented in virtually any hospital unit setting Lead by charge nurses per unit Discussion: developmentally & age appropriate pain assessment tools (FLACC) for the preverbal patient population

Potential Barriers Staff response to change Attitude & unwillingness Loss of independence Post intervention, pediatric nurses reported increased FLACC scale use, increased pain assessment, improved staff responsiveness to pain, as well as greater satisfaction with assessment tools (Treadwell, Franck, & Vichinsky, 2002; Vael & Whitted, 2014) Another barrier: Lack of adherence once implemented We need adherence criteria in terms of further policy development or amendment to policy stating specific adherence criteria hospital must maintain

Ethical Considerations To comply with patient rights & justice frameworks, assessment of pain in all patients is required by JCAHO Ethical concern for any patient if needs are not met during one’s hospital stay Pain is physical, emotional, and spiritual for many patients, and every patient has the right to have their pain assessed & managed to provide quality, personalized, patient-centered care (O’Brien, 2014) Justice – decency to provide quality care which means assessing and managing pts pain Beneficence – non-maleficence in order to do good by our pts and prevent we must obtain baseline data so we know the tolerance and levels of pain to treat pain adequately to keep our pts comfortable if the pt can’t speak for themselves then it is our duty as that pts advocate to assess pain and treat accordingly

Expected Outcomes Increased assessment, documentation & management of pain Decreased pain Increased nurse awareness (Vael & Whitted, 2014)

Modes of Measurement Documentation of pain assessment Patient charts Decreased pain after assessment & treatment Scores in the documented categories of face, legs, activity, cry, and consolability, within patient charts, will be evaluated to measure pain assessment and management post-intervention (Vael & Whitted, 2014). How will we measure this? Pain assessment will be documented in the pt chart and we will measure the decreased pain per category documented by using the FLACC scale FLACC – ranges from 0 to 2, each category Faces, legs, activity, cry, consolability from 0 to 2 progressing from no signs of pain, to signs of pain and distress, per category

Conclusion Nurse education is cost-effective Easily implementable intervention Increases nurse awareness (Vael & Whitted, 2014) Improves assessment & reduces pain in preverbal pediatric patients

Reference Baulch, I. (2010). Assessment and management of pain in the paediatric patient. Nursing Standard, 25(10), 35-40. Retrieved from http://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?sid=c3a62a2f-7392-4c20-9bfc- 4b2e39f39c69%40sessionmgr4005&vid=1&hid=4102 Bear, L., & Ward-Smith, P. (2006). Interrater reliability of the COMFORT scale. Pediatric Nursing, 32(5), 427. Retrieved from http://eds.a.ebscohost.com/eds/detail/detail?sid=62f3324e-cee4-4492-bc68 -e2d383a7c0a0%40sessionmgr4004&vid=0&hid=4202&bdata=JnNpdGU9ZWRzLWxpd mU%3d#db=rzh&AN=2009314878 Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., Williamson, K.M. (2010). Critical appraisal of the evidence: Part I. AJN, 110(7). 47–52. Johansson, M., & Kokinsky, E. (2009). The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care. Nursing In Critical Care, 14(3), 122-130. doi:10.1111/j. 1478- 5153.2009.00323.x O'Brien, M. (2014). The nurse-patient relationship: A caring ministry. In Spirituality in nursing standing on holy ground (5th ed., pp. 87-113). Burlington, MA: Jones and Bartlett Pub.

Reference Pain management for children. (2001, April 1). Retrieved March 20, 2015, from http://www.health-first.org/ health_info/your_health_first/kids/pain.cfm Smyth, W., Toombes, J., & Usher, K. (2011). Children's postoperative pro re nata (PRN) analgesia: Nurses' administration practices. Contemporary Nurse: A Journal For The Australian Nursing Profession, 37(2), 160-172. doi:10.5172/conu.2011.37.2.160 Stanley, M., & Pollard, D. (2013). Relationship between knowledge, attitudes, and self-efficacy of nurses in the management of pediatric pain. Pediatric Nursing, 39(4), 165-171. Retrieved from http://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?sid=13cb2ab0-ad03-4990-8897- d3f2a124db30%40sessionmgr4004&vid=1&hid=4102 Treadwell, M., Franck, L., & Vichinsky, E. (2002). Using quality improvement strategies to enhance pediatric pain assessment. International Journal for Quality in Health Care, 14(1), 39-47. doi: http://0- dx.doi.org.patris.apu.edu/10.1093/intqhc/14.1.39 Vael, A., & Whitted, K. (2014). An educational intervention to improve pain assessment in preverbal children. Pediatric Nursing, 40(6), 302-306. Retrieved from http://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?sid=0b594679-3f29-4271-9c12- 13dd08e4c63e%40sessionmgr4004&vid=1&hid=4102

Reference Van Hulle Vincent, C., Wilkie, D., & Wang, E. (2011). Pediatric nurses' beliefs and pain management practices: an intervention pilot. Western Journal of Nursing Research, 33(6), 825-845. doi: http://dx.doi.org/10.1177/0193945910391681