1. Comfort, Function and Pain in Pediatric Patients Joey Robinson, MSNEd, Clinical Educator PCMC, Surgical Services June, 2007

2. Comfort and Pain Management Goal This presentation is for pediatric nurses. Please review –FAQ sheet –Teaching checklist Comfort –LTA Pain and Comfort Function Goals –CPG comfort link located in basic cares and pain management documents –This module takes approximately 15 minutes to read.

3. Comfort and Pain Management Goal Objectives –The learner will be able to give examples of comfort. –The learner will be able to define the difference between comfort, function and pain. –The learner will be able incorporate the principals of comfort, function and pain in nursing plans of care.

4. Why is defining comfort, function and pain important? –In the past 15 years, in spite of efforts made to alert health care providers to the problem of under treated pain very little has changed. –Children are routinely under medicated for pain –At the heart of this issue is the failure to hold members of the health care team accountable for providing the best possible pain relief to their patients (Apfelbaum, J.L. 2003, Whalen, C.T. et al 2004).

5. Comfort and Function One solution to the problem of under-treated pain has been to establish functional goals –Functional goals Routinely discussed with patients and families and be part of the interdisciplinary plan list (IPL) Related to surgery can be –To control nausea and vomiting –Stand, crawl or ambulate after surgery with minimal discomfort ( 3 – 4 might be appropriate). –When setting function goals a nurse needs to remember that patients/families don’t necessarily know either the importance of pain relief or how much pain relief to expect (Pasero C., McCaffery, M., 2004).

6. Comfort and Pain Management Goal Why is setting a pain management goal important? –By setting pain rating goals that correspond to function, patients/families learn no surgery and many diagnosis's are not pain free and comfort helps their child recover faster (Pasero C., McCaffery, M., 2004). Setting post operative and diagnosis related comfort and function offers the nurse the opportunity to discuss with the parents; Methods for comforting their child that have worked previously –thumb sucking, blanket holding, patting, rocking, special item, singing Pain behaviors/expression or history –Grimacing, frowning, restlessness, crying, repetitive motion, howling (cognitively impaired) Non-pharmacological methods of comfort – warm, cold, music, distraction

7. Comfort and Pain Management Goal The state of comfort is more than the absence of discomfort. Definition of comfort for nursing (Kolcaba, 1994, 2001, 2003) is defined as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psycho spiritual, socio cultural and environmental)” (2003, p. 251).

8. Comfort and Pain Management Goal Pediatric nursing’s foundation facilitates a child’s special self-comfort habits such as: –Thumb sucking –Blanket holding –Rocking –Positioning for comfort –Advocating for the presence of family (Stephens, Barkey & Hall, 1999).

9. Comfort and Pain Management Goal Children and families want to be comforted in stressful situations –Prevention of discomforts, including those related to physiological or psychological stressors is easier than treating discomforts. Prevention is also better for children/families. (Kolcaba, M., DiMarco, M., 2005),

10. Comfort and Pain Management Goal Nurses facilitate a supportive environment for recovery and rehabilitation. Nurses are coaches in pediatric settings, assuring the child/family that (s)he can recover, is safe, is protected from harm and is capable to participate in the treatment plan appropriate to her/his developmental age (Kolcaba, M., DiMarco, M., 2005).

11. Comfort and Comfort Function Goal A 9 month old that has been adequately medicated for a hernia repair. (S)he has not been reunited with his/her parent and has an IV in his thumb sucking hand. Is this child in pain? Is this child comfortable?

12. Comfort and Pain Management Goal Remember, if we treat the patient’s pain and comfort, the perceptions of pediatric pain management could be improved. –Comfort is an important outcome to measure for pediatric care and research. Linked to higher patient satisfaction ratios Linked to cost-benefits ratios (Kolcaba, 2003)

13. Comfort and Pain Management Goal Please stop at this point and write down one thing you will incorporate into your practice regarding comfort and pain management goals. OR Briefly discuss comfort, function and and pain management and its importance with a colleague.

14. Implementation –Pre-operatively/pre-procedure nurses may discuss comfort and pain management goals with the parent or child document this goal pre-operative/pre- procedure –Include information regarding: what comforts their child how they act when they are in pain (especially cognitively impaired and preverbal) special item they have brought to the hospital to comfort their child.

15. Additionally –This information should be communicated and documented on the appropriate form –During hand off communication this information will be communicated to the next care member of the team using SBAR under “personal belongings” anything that comforts the child “pain” section where pain, comfort and function goals are written.

16. Pain Management Goal Any pain score that exceeds goal requires intervention. –This intervention does not have to be pain medication! –It can be swaddled in a warm blanket, rocked and burped. Anything that indicates to the patient and family that comfort/pain has been addressed. –The intervention may include an explanation to patient or family to better understand the patient will continue to be upset until they get used to the feeling of what’s “new”.

17. Comfort and Pain Management Goal Comfort, function and pain will be discussed with parents and patients during routine care of the patient to insure all these needs have been met. Goals and assessment will be documented on IPL, flow sheet and surgical forms

18. Comfort and Pain Management Goal Patient education tools available for use now include: –Let’s Talk About Surgical Pain and Comfort –Pain management goals teaching checklist Keep an eye out for the development of upcoming patient education

19. Comfort and Pain Management Goal Multi disciplinary tools are available on the pediatric clinical program page. Intermountain.net > Clinical programs > Pediatric specialty > Provider education

20. Comfort and Pain Management Goal You should be able to: –Implement comfort, function and pain into your practice –Find the FAQ sheet, Teaching checklist “Pain Management Goals”, LTA “Surgical Pain and Comfort Function Goals”, CPG under basic cares –Discuss comfort, function and pain with a colleague, educator or manager to increase your learning retention.

21. Comfort and Pain Management Goal References Kolcaba, M., DiMarco, M., (2005), Comfort Theory and Its Application to Pediatric Nursing, Pediatric Nursing, (31) 3 187- 193. Pasero C., McCaffery, M., (2004) Comfort-Function Goals Pain Control, AJN, (104) 9 77-79. Apfelbaum, J.L. Postoperative pain experience:results for a national survey suggest postoperative pain continues to be undermanaged. Anesthesia Analog 2003:97 (2): 534-40 Whalen, C.T. et al, Pain and satisfaction with pain control in hospitalized medical patients: no such thing as low risk. Arch Internal Medicine 2004; 164 (2): 173-80. Kolcaba, K. (1991) A Taxonomic Structure for the Concept Comfort Journal of Nursing Scholarship, 23(4) 237-240