1. Pain Assessment and Management in Children
Chapter 5
Pain Assessment and Management
in Children

2. Consequences of Pain Children of All Ages Can Perceive Pain
Unrelieved Pain Is a Major Stressor
Physiologic
Psychologic
Repeated Pain in Infants Can Lead to Future Sensitivity
Self-Protective Behavior Due to Pain Can Delay Healing

3. PAIN BEHAVIORS Acute Pain.
Acute Pain
Short attention span, irritability, grimacing, posturing, limb flexion, sleep disturbances, lethargy, withdrawal .
* * See Box 5-1 Children’s Responses to pain at various ages, P. 153, Wong

4. Pain Behaviors
Chronic Pain
Physiologic adaptation may mask signs

5. Pain Scales Choose Developmentally Appropriate Scale
Behavioral and self-report types
Determine child’s ability to demonstrate concepts of degree, rank order, estimation, and classification

6. Behavioral Pain Scales
CRIES (p. 160, Wong)
Crying, Requires O2, Increased vital signs, Expression, Sleeplessness
FLACC (p. 159, Wong)
Face, Legs, Activity, Cry, Consolability
NIPS (Neonatal Infant Pain Scale) (p. 159, Wong)
Expression, cry, breathing, arm and leg movements, arousal state

8. Table 15-5 FLACC Behavioral Pain Assessment Scale

9. Self-Report Scales: Body Outline Faces Oucher (see next slide)
Poker Chip
Numeric Rating
Word-Graphic Rating

11. Non-pharmacologic Strategies for Pediatric Pain Management
List 4 non-pharamalogic strategies for pain management in the:
Infant toddler/preschool school-age/adolescent
___________________ __________________ ___________________

12. Non-narcotic pain relief
Used for relief of mild to moderate pain or chronic pain
May be used in combination with opioid to
effectiveness and amt. of narcotic needed
Non-opioid analgesic: acetaminophen
NSAIDS:
Ibuprofen (available in liquid form)
Naproxen (available in liquid form)
Ketorolac (Toradol) see indications in text
Aspirin (is not used in children <19 years old with possibility of viral illness)
(See Table 5-4 Wong, p. 171)

13. Opioid Use: ie, morphine & hydromorphone, fentanyl
Severe Pain or Injury
Route: Oral, IM, IV
Determine equianalgesic dose (see p.176, Table 5-8)
Based on drug, child’s weight
Avoid IM route if possible
Monitor Effects
Common: sedation, nausea, vomiting, itching, constipation, urinary retention

14. Opioids
Often combined with a non-opioid to provide increased analgesia without increased side effects. (Ex. Tylenol No. 2 contains 15 mg codeine with 300 mg acetaminophen)
Morphine is considered the gold standard for management of severe pain.
Effective morphine substitutes used in pediatric client include hydromorphone (Dilaudid) and fentanyl (Sublimaze)

15. Opioid Risks: Respiratory Depression Unresponsive
Respiratory rate less than 12 breaths per minute
Cardiovascular Collapse
Addiction
Very rare

16. Define the following terms as pertaining to pediatric pain:
Physical dependence
Withdrawal
Tolerance
Over what period should children be weaned off opioids to prevent withdrawal symptoms?

17. Pediatric pain relief:
PCA-generally used for children 7+ years old and able to press button
Most useful first 48 hr. post surgery

18. Regional Pain Management:
Local nerve block: ie, regional femoral block
Epidural nerve block:

19. EMLA (p. 730, Ball) (Eutectic Mixture of Local Anesthetics)
Combination of lidocaine 2.5% and prilocaine 2.5% in an emulsion.
Apply a thick layer of cream to intact skin & cover with occlusive dressing
Leave in place 1 hr. for minor procedure, 2 hrs. for major procedure.

20. Nonpharmacologic Methods
Gate Control Theory
Inhibitory neuron stimulation
reduces pain sensation
Can Enhance Effects of Analgesics
Methods
Distractions
Stimulations

21. 24% Sucrose Solution
Sweet-Ease is a 24% sucrose and purified water solution which significantly reduces discomfort in the infant. It may be used in all areas where infants are seen: NICU, PICU, ER and pediatrician’s offices.
Packaged in 2 convenient sizes:
2m. Vial to administer directly onto tip of infants tongue or buccal surface.
15 ml translucent, spill resistant cup which allows for dipping a pacifier into the cup.

22. Acute Pain: Nursing Care
Assess Pain
Situational factors
Cognitive, behavioral, emotional
Use appropriate assessment tool
Partner with parents
Typical reactions? Effective relief strategies?

23. Acute Pain: Nursing Care (cont’d)
Planning and Implementation
Evaluate prescribed analgesics
Mg of drug per kg of body weight
Drug choice for level and quality of pain
Appropriateness of interval, route
Nonpharmacologic methods
Appropriate complementary therapies

24. Acute Pain: Nursing Care (cont’d)
Evaluate
Effectiveness of analgesics, complementary therapies
Time, quality of relief
Understanding by child and parents of management

25. Clinical Therapies: Acute Pain
Analgesics and Complementary Therapies May Be Used for Acute Pain
Complementary Therapies May Decrease Amount of Medication Needed for Acute Pain

26. Clinical Therapies: Chronic Pain
Individualized Treatment Plan Focusing on Improved Function and Comfort
Analgesics Often Prescribed In Combination

27. Clinical Therapies: Chronic Pain (cont’d)
Other Medications
Transdermal fentanyl patches
Tricyclic antidepressants
Gabapentin
Exercise and Physical Therapy to Promote Improved Function
Complementary Therapies

28. Procedure Sedation/Analgesia
Before Procedure
Explain expected sensations
Use topical anesthetics
Avoid delays
During Procedure
Monitor for respiratory depression
Visual confirmation and pulse oximetry
Check vital signs every 15 minutes

29. Procedure Sedation/Analgesia (cont’d)
After Procedure
Assess cardiovascular and respiratory function
Assess arousability
Assure adequate hydration
Protect from injury
Falls from bed, while ambulating

30. Summary Children of All Ages Perceive Pain
Unrelieved Pain Is a Major Physiologic and Psychological Stressor
Nurses Must Be Able to Assess a Child’s Pain
Both Pharmacologic and Nonpharmacologic Interventions May Relieve Pain

31. Resources
City of Hope Pain/Palliative Care Resource Center Web site.

32. Resources (cont’d)
American Pain Society A multidisciplinary organization of basic and clinical scientists, practicing clinicians, policy analysts, and others. The mission of the American Pain Society is to advance pain-related research, education, treatment, and professional practice.

33. Resources (cont’d)
The International Association for the Study of Pain (IASP) pain.org The largest multidisciplinary international association in the field of pain.
Wisconsin Pain Initiative The WPI is dedicated to overcoming the barriers that prevent the relief of pain.
City of Hope Pain/Palliative Care Resource Center Web site.