1. Pediatric Pain Assessment Pediatric Pain Assessment Susan Harp, RN Division of Pediatric Anesthesia and Pain Management

2. Goals of Pain Assessment “Provide accurate information to determine which actions could be taken to alleviate the pain, and, on an ongoing basis evaluate the effectiveness of these actions.” “Provide accurate information to determine which actions could be taken to alleviate the pain, and, on an ongoing basis evaluate the effectiveness of these actions.” Judith Beyer and Nancy Wells, PEDIATRIC CLINICS OF NORTH AMERICA,1989 Judith Beyer and Nancy Wells, PEDIATRIC CLINICS OF NORTH AMERICA,1989 Pediatric Pain Management P R O G R A M

3. Pain Assessment LocationLocation CharacteristicsCharacteristics Onset / DurationOnset / Duration FrequencyFrequency QualityQuality Intensity / SeverityIntensity / Severity Precipitating FactorsPrecipitating Factors Pediatric Pain Management P R O G R A M

4. Assessment Tools Self-Report “The Gold Standard”Self-Report “The Gold Standard” Observational ScalesObservational Scales Physiologic ParametersPhysiologic Parameters Parent ReportParent Report Nurse ReportNurse Report Pediatric Pain Management P R O G R A M

5. Self-Report Description of Pain - type of pain - intensity of painDescription of Pain - type of pain - intensity of pain Pain Scale RatingsPain Scale Ratings Pediatric Pain Management P R O G R A M

6. Observations Vocalization / verbalizationVocalization / verbalization Facial ExpressionFacial Expression Body LanguageBody Language Emotional StateEmotional State Pediatric Pain Management P R O G R A M

7. Physiologic Parameters Heart rateHeart rate Respiratory rateRespiratory rate Blood pressureBlood pressure Pediatric Pain Management P R O G R A M

9. Parent Vs. Nurse Report Varying results in studies comparing parent, nurse, and self-reportVarying results in studies comparing parent, nurse, and self-report May be especially useful in cognitively impaired childrenMay be especially useful in cognitively impaired children Pediatric Pain Management P R O G R A M

10. Special Situations Cognitively impairedCognitively impaired Cerebral palsy with normal cognitive levelCerebral palsy with normal cognitive level Hearing or vision impairedHearing or vision impaired Non-English speakingNon-English speaking Intubated / paralyzed patientsIntubated / paralyzed patients Pediatric Pain Management P R O G R A M

11. Developmental Factors Newborns and small children unable to give self-reportNewborns and small children unable to give self-report However, avoidance behavior has been shown by at least 6 months of ageHowever, avoidance behavior has been shown by at least 6 months of age Consistency of facial and cry response has been shown in neonates and infantsConsistency of facial and cry response has been shown in neonates and infants Children 3-5 yrs are able to use some self-report measures, localize painChildren 3-5 yrs are able to use some self-report measures, localize pain Pediatric Pain Management P R O G R A M

12. Assessment in Neonates Neonatal Infant Pain Scale (NIPS)Neonatal Infant Pain Scale (NIPS) Objective Pain Scale (OPS)Objective Pain Scale (OPS) CriesCries Parent ReportParent Report Nurse ReportNurse Report Physiologic MeasuresPhysiologic Measures Pediatric Pain Management P R O G R A M

13. Neonatal Infant Pain Scale (NIPS) Facial Expression - relaxed, grimaceFacial Expression - relaxed, grimace Cry - no cry, whimper, vigorousCry - no cry, whimper, vigorous Breathing patterns - relaxed, changedBreathing patterns - relaxed, changed Arms - relaxed, flexed/extendedArms - relaxed, flexed/extended Legs - relaxed, flexed/extendedLegs - relaxed, flexed/extended State of Arousal - sleeping/awake, fussyState of Arousal - sleeping/awake, fussy Lawrence J, et. al Pediatric Pain Management P R O G R A M

14. Objective Pain Scale (OPS) Blood pressure - 10%, 10-20%, 20- 30% preopBlood pressure - 10%, 10-20%, 20- 30% preop Crying - not crying, crying +/- response to TLCCrying - not crying, crying +/- response to TLC Moving - none, restless, thrashingMoving - none, restless, thrashing Agitation - calm, mild, hystericalAgitation - calm, mild, hysterical Broadman LH, Hannalah RS, et.al Pediatric Pain Management P R O G R A M

15. Objective Pain Scale (OPS) Verbal Eval / Body Language - asleep/states no pain - mild pain (cannot localize) - moderate pain (localizes)Verbal Eval / Body Language - asleep/states no pain - mild pain (cannot localize) - moderate pain (localizes) Broadman LH, Hannalah RS, et.al Pediatric Pain Management P R O G R A M

16. Assessment in Infants and Children < 3 Years OPSOPS CHEOPSCHEOPS Parent ReportParent Report Nurse ReportNurse Report Physiologic MeasuresPhysiologic Measures Pediatric Pain Management P R O G R A M

17. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) Cry - None, Moaning, Crying, ScreamingCry - None, Moaning, Crying, Screaming Facial - Composed, Grimace, SmilingFacial - Composed, Grimace, Smiling Verbal - None, Other, Pain, Both, PositiveVerbal - None, Other, Pain, Both, Positive Torso - Neutral, Shifting, Tense, Shivering, Upright, RestrainedTorso - Neutral, Shifting, Tense, Shivering, Upright, Restrained Touch - None, Reach, Touch, Grab, RestrainedTouch - None, Reach, Touch, Grab, Restrained Legs - Neutral, Squirming, Drawn-up, Standing, RestrainedLegs - Neutral, Squirming, Drawn-up, Standing, Restrained Pediatric Pain Management P R O G R A M

18. Assessment in Children 3-6 Yrs Faces ScaleFaces Scale Oucher ScaleOucher Scale Poker Chip ToolPoker Chip Tool Visual Analogue Scale (VAS)Visual Analogue Scale (VAS) Observation ToolsObservation Tools Parent ReportParent Report Nurse ReportNurse Report Pediatric Pain Management P R O G R A M

19. 4681002 FACES Rating Scale Adapted from Wong/Baker FACES Rating Scales Wong, D and Whaley, L: Clinical Handbook of Pediatric Nursing ed.2, p. 373, St. Louis, 1986, The C.V. Mosby Company. Pediatric Pain Management P R O G R A M

20. 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 10 10 20 20 0 Pediatric Pain Management P R O G R A M OUCHER!

21. 2 3 5 4 1

22. 012345 6 78910 No Pain Worst Possible Pain!! Numerical Rating Scale Pediatric Pain Management P R O G R A M

23. Assessment in Children > 6-7 Yrs Self-Report - VAS - Numerical Ranking ScaleSelf-Report - VAS - Numerical Ranking Scale Observational ScalesObservational Scales Parent ReportParent Report Nurse ReportNurse Report Pediatric Pain Management P R O G R A M

25. “Golden Rule” of Pain Assessment Don’t forget to ask the patient !!!Don’t forget to ask the patient !!! Pediatric Pain Management P R O G R A M

26. Pain Assessment in Children “Pain is whatever the patient says it is.” Pediatric Pain Management P R O G R A M

27. Infants do feel painInfants do feel pain Children do not tolerate pain better than adultsChildren do not tolerate pain better than adults Children can tell you where they hurtChildren can tell you where they hurt Children do not always tell The truth about painChildren do not always tell The truth about pain Pediatric Pain Management P R O G R A M Facts About Children & Pain

28. Children do not become accustomed to pain or painful proceduresChildren do not become accustomed to pain or painful procedures Behavioral manifestations of pain may not reflect pain intensityBehavioral manifestations of pain may not reflect pain intensity Narcotics are no more dangerous for children than adultsNarcotics are no more dangerous for children than adults Pediatric Pain Management P R O G R A M Facts About Children & Pain

29. Pediatric Pain Management P R O G R A M