Laura Salisbury RN, MSN/Ed. Chapter 7: Pain assessment and management in children

Pain Assessment Distress behaviors: What are these? Developmental characteristics of pain response (see box 7-1, p. 159) Three types of measures to assess child’s pain: Behavioral Physiologic Self-report When are these measures accurate? What makes them inaccurate?

Pain rating scales for Children FACES FLACC OUCHER Poker chip tool Word-graphic rating scale Numeric scale VAS (visual analog scale) Color tool

Pain in Neonates Difficult to assess Can only be based on physiologic and behavioral responses Assessment tools: CRIES PIPP (Premature Infant Pain Profile) NPASS (Neonatal Pain, Agitation, and Sedation Scale)

Pain in Children with Communication and Cognitive Impairment At greater risk for under treatment of pain Primary caregiver important source of information Pain measurement tools: Non-communicating Children’s Pain Checklist PICIC (Pain Indicator for Communicatively Impaired Children)

Pain in Children with Communication and Cognitive Impairment Cultural issues: what may affect cultural appropriateness of pain assessment? Children with Chronic Illness and Complex Pain Important components of assessment: what are they?

Pain Management Nonpharmacologic management Virtual reality Containment/swaddling/tucking Nonnutritive sucking/with or without sucrose Kangaroo care Complementary pain medicine

Pharmacologic management Based on weight until 50 kg (110 lbs) Acetaminophen (15 mg/kg) NSAIDS (10 mg/kg) Opioids Adjuvants

Routes and Methods of Analgesic Drug Administration Oral PCA: Patient- controlled/nurse-parent controlled Transmucosal IV/Sub-Q Intramuscular Intranasal Intradermal Transdermal/topical EMLA LAT Numby Stuff Epidural/Intrathecal Rectal Regional nerve block Inhalation

Monitoring and treatment of side effects from opioids Respiratory depression Constipation Pruritis Nausea/vomiting Sedation Physical dependence Withdrawal Tolerance Addiction (psychologic dependence)

Evaluation of therapy Possible effects of pain in infancy/childhood Painful and Invasive Procedures/Postoperative pain Use of nitrous oxide Surgery and traumatic injury generate a catabolic state Preemptive analgesia Multimodal analgesia

Recurrent headaches in children Recurrent abdominal pain in children Cancer pain in children Peripheral neuropathy End-of-life pain and sedation

Laura Salisbury RN, MSN/Ed. Chapter 22: Pediatric variations of Nursing Interventions

Informed Consent Patient assent When is treatment given without parental consent?

Preparing children for procedures Doing the procedure Treatment room Be confident Use distraction OK to express feelings; OK to cry After procedure: Allow venting, give positive reinforcement

Surgical Procedures Advantages vs. disadvantages of keeping parent with child until anesthesia Preoperative sedation: necessary? Fasting before hand? (Table 22-1, p. 696) Postoperative care Symptoms of malignant hyperthermia; how is it treated?

General Hygiene and Care See Skin Care guidelines, box on p. 700 What is epidermal stripping? How do you encourage nutrition? Fluid intake?

Controlling increased temperature Fever vs. hyperthermia: what is the difference? Fever: antipyretic FIRST, then cooling measures: don’t allow shivering Antipyretics do not prevent febrile seizures Hyperthermia: Antipyretics will not work Concerning signs: See box p. 704

Safety Accurate identification: how? Prevent falls: how? Infection control: KNOW BOX 22-5 p. 707: types of precautions and patients requiring them The most critical infection control practice is: How should pediatric patients be safely transported?

Restraints Behavioral: Rarely used in pediatrics Medical-surgical: when are they used? What precautions should be taken? Temporary restraint (procedural): what is therapeutic holding? Mummy restraint, swaddle, jacket restraint, arm/leg restraints, elbow restraints How are children positioned for an LP?

Specimen collection Urine: how? Getting out of disposable diaper (see “FYI” p. 712) What is suprapubic aspiration? When is it used? Stool: How? Blood Out of saline lock Arterial: do Allen test first Infant heel puncture: how do you do it safely? Where to you puncture Sputum: Nasal washing

Administration of Medications Oral route: measure accurately! Do not mix meds with bottle; know when you can crush pills Use of an oral syringe to get med into an infant Intramuscular: use vastus lateralis in the infant; can use ventrogluteal all ages; deltoid in older children, when small amount of med (How much can be given in a single shot in each site?) See guidelines box, p. 721

Administration of Medications IV devices Saline lock: short term Central access: Non-tunneled catheters PICC lines Rectal Rectum needs to be empty; can be difficult to get the right dose NG/OG/Gastrostomy: see guidelines p. 730 Eye drops: careful not to contaminate

Fluid Balance Maintaining fluid balance 1 gram wet diaper weight=1 mL urine Dealing with children who are NPO/fluid restricted Parenteral fluid Rehydration methods ORS IV Fluid

Site Selection  Avoid dominant hand; avoid foot/leg in children who are walking  When rapid IV access needed, can’t get IV site: Intraosseous (runs just like an IV)  Secure the site…but allow for circulation assessment distally; watch for infiltration  How do you remove tape?  What is the difference between infiltration and extravasation?

Oxygen Therapy Hood Nasal cannula Oxygen tent Mask not usually tolerated Oxygen toxicity: retina of preterm infants; lungs damaged with excessive use What is oxygen-induced carbon dioxide narcosis? Pulse oximetry: Change site frequently to avoid burns, necrosis

Respiratory treatments Aerosol therapy Handheld nebulizers MDI: use a spacer Postural drainage: what is it? When used? Chest physical therapy: What is it? When used?

Artificial Ventilation Nasotracheal intubation preferred over endotracheal when possible Only uncuffed endotracheal tubes for children less than age 8 Always humidify air/gas being delivered directly to trachea Tracheostomies: What do we watch for? Suctioning: NO MORE than 5 seconds: hyperventilate with 100% oxygen pre and post; no more than 3 passes at a time; only as often as needed What if tube is totally occluded or it comes out? What to do?

Alternative Feeding Gavage feeding Flows in by gravity Give infants something to suck on Gastrostomy tubes (G-tubes): may flow in by gravity or be put on pump Nasoduodenal, nasojejunal: When are these used? What tells us that it may be in the wrong place? Always verify placement by X-ray before first use TPN: Control risk of sepsis, watch infusion rate, assess patient’s tolerance

Enemas and Ostomies Use isotonic solutions; Don’t use Fleet enema (not even the pediatric Fleet!) Particularly distressing for preschool child Children can be taught to manage own ostomy appliance; adolescents especially disturbed by ostomy