1. Pediatric Pain Management
Presented by: Danyel Dorn RN, MSN, CPN, Clinical Nurse Educator-Pediatric Service Line

2. The Joint Commission mandates that all individuals have the right to effective pain/symptom management. This mandate must be included in the delivery of basic clinical nursing care. The Agency for Healthcare Research and Quality asserts that institutions have the responsibility for pain management and that this responsibility begins with the affirmation that patients should have access to the best level of pain relief that may be safely provided.
Purpose

3. Neonates, infants, young children, critically ill and postanesthetic patients are at a higher risk for increased pain related to their inability to communicate effectively. It is essential that perianesthesia registered nurses caring for pediatric patients develop competency and expertise in assessment and management of pain in children.
Purpose

4. The perianesthesia registered nurse will be able to perform safe, individualized pharmacologic and non-pharmacologic pain interventions with pediatric patients in perianesthesia settings using “skills of assessment, evaluation and decision-making.”
Competency Statement

5. Criteria Key elements of a comprehensive pediatric pain assessment
Preoperative pain assessment
Parent description of how patient expresses pain, words his/her child uses to express pain and anxiety
Behavioral observation
Current pain location, intensity, description (age appropriate)
Reassessment after interventions
Type of measurement scale used (FLACC, Numeric, FACES)
Criteria

6. Pharmacologic Pain Interventions
Normal dosages for the pediatric patient vary according to weight; therefore, doses can be constantly changing dependent upon the size and age of the child.
The volume of smaller doses leaves very little room for error.
Pharmacologic Pain Interventions

7. Nonopiod/NSAIDS Analgesics
Acetaminophen: given by mouth (PO), rectally (PR), intravenously (IV)
Serum concentration peaks 60 minutes after administration
Can be effective when given preoperatively for short procedures (myringotomy, ear tube placement)
NSAIDS-Ibuprofen: given orally, ketorolac is given IV
Nonopiod/NSAIDS Analgesics

8. Fentanyl: given IV in intermittent doses, should be titrated to appropriate analgesic effects to minimize adverse effects
Fentanyl can be given via IV, Epidural, PCA, Intranasal
Morphine: given IV, ordered intermittent doses, titrated to comfort
Can be given continuous IV, epidural infusion, PCA
Opioid Analgesics

9. Hydromorphone: given IV in intermittent doses and should be titrated to appropriate analgesic effects, while minimizing adverse effects
May be given continuous IV, epidural, PCA
Oxycodone/acetaminophen: PO
Hydrocodone/acetaminophen: PO
Opioid Analgesics

10. Opioid Adjuncts Clonidine: IV, continuous epidural infusion
Precedex (dexmedetomidine): co- administration with anesthetics, sedatives, hypnotics and opioids
Can enhance the pharmacodynamic effects of these agents
Opioid Adjuncts

11. Multi-modal Pain Management
The process of combining pharmacologic, cognitive behavioral and physical approaches to pain management
Utilizing opioid and non-opioid medication therapies, to maximize pain control while minimizing opioid related side effects
Utilization of heat, ice and/or positioning to promote comfort
Promoting wake/sleep cycles to promote rest to assist children with coping skills
Utilization of child life therapy to assist with coping mechanisms
Multi-modal Pain Management

12. Codeine/acetaminophen: codeine is no longer recommended by the FDA due to its unstable metabolism
In August 2012, the FDA warned the public that this danger exists for children who are “ultra-rapid metabolizers” of codeine, meaning that their liver converts codeine to morphine in higher than normal amounts
Patient response to medications should be assessed, documented and pain assessment repeated according to institutional policy
Warning

13. Dosing Charts

14. Dosing Charts

15. Non-pharmacologic Pain Interventions
Infants and neonates: nonnutritive sucking, swaddling, reduction of external stimuli, skin to skin contact, oral sucrose, and breastfeeding.
Children: position for comfort, thermal measures, distraction (play activities, TV, music), relaxation techniques, reduced lighting, massage and family presence.
Non-pharmacologic Pain Interventions

16. Non-pharmacologic Pain Interventions
Adolescents: Position for patient comfort, thermal measures, distraction, phone movies/TV music, imagery, relaxation techniques, reduced lighting, massage, allowing control of environment, deciding when family can visit, maintain modesty and privacy to help decrease anxiety, family friend (boyfriend/girlfriend) presence and participation.
Non-pharmacologic Pain Interventions

17. Medication Administration
Utilize two patient identifiers when double checking medication and confirming it is the correct patient
Confirm correct order for analgesia
Confirm dose and patient weight
Implement weight based dose calculations: dosing is generally in mg/kg per doses
Double check medication with another nurse per institution protocol – patient identification, weight, allergies, medication name, dose ordered, visual of both the container or package the medication came from as well as the drawn up medication to allow confirmation by the verifying nurse for each dose given.
Medication Administration

18. Medication Administration
Discuss pain management options with parents
Parents need education about how to give medication, what to expect, various side effects and reassurance that opioid pain medication is safe for pediatric patients when dosed correctly
Discuss the role of family in pediatric pain control
Encourage parents to remain calm to promote decrease anxiety for child
Medication Administration

19. Medication Administration
Instruct the parents to not continually ask the child, “are you in pain?” but watch activities and medicate appropriately as directed
Teach the parents to follow the medication directions and discharge instructions
Inform the parents who to contact if they are concerned there is additional pain
Do not tell children, “This is candy”
Tell the patient it is medication and he/she needs to take it to help them feel better
Medication Administration

20. Medication Administration
Never as a child, “Are you ready for your medicine?” or “Do you want your medicine?” This is not the choice. The choice is, “Do you want me to give it to you or do you want mommy/caregiver to give it to you?”
Explain that some medications do not taste good, but it is still important to take it. Children respond well to honesty and being ready to expect certain things. Have a popsicle or juice ready to get rid of the taste of the medicine
Do not put medication into a cup or bottle of formula or other liquid. The nurse and the parent need to be aware of the exact dose of medication being administered
Medication Administration

21. ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.
Reference

22. D C B A
Answers