Chapter 39 Pain Management in Children
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Chapter 39 Pain Management in Children
nursing pediatrics pain management RN
Pain management for Children for nursing
Why might parents be reluctant to allow pain meds for their child?
fears about side effects from opiods and addiction
What is a common risk with children and pain management?
What children are the most at risk?
pain goes unrecognized and undertreated
med/therapy given along with the main therapy
whatever person having pain says it is, existing whenever the person says it does
Gate control theory of pain?
How does it support that physiological and psychological treatments may help with pain?
There is a gating mechanism in the dorsal horn of the SC that regulates conduction of pain signals from peripheral NS to the brain.
Physically - if large fibers are stimulated it blocks the ability of small fibers to open the gate and send pain signals to the brain; this reduces sensation of pain
EXAMPLE: rubbing the injured area
psychological: it is believed that attention, emotion, and memory influence the gate
3 characteristics of acute pain?
1. usually has sudden onset
2. from an identifiable trauma
3. continues for a limited time
What usually resolves acute pain?
healing of the trauma that caused it
What acute pain may children experience when hospitalized/being cared for?
Acute pain becomes ______ if it persists.
3 characteristics of chronic pain?
1. continues for unpredictable period beyond expected recovery period
2. unlikely to resolve quickly
3. may adversely affect ADL's
_______ pain is very hard to treat because it responds poorly to opioids.
How can the assessment and treatment of childhood pain be improved?
education for professionals
What is the basis for pain management in children and adults?
What are the guidelines for pain management?
WHO's 3-step analgesic ladder
1. nonopioid analgesics for mild pain
2. weak opiods for mild to moderate pain
3. opiod analgesics for severe pain with accessory meds used for breakthrough pain
American Pain Society
What 2 things does the Joint Commission require from healthcare facilities regarding pain management?
1. pain management education
2. right of all pt to have appropriate pain management from admission to discharge
What may occur due to the repeated experience of pain in neonates
emotional, behavioral and learning disabilities later in life
What are the challenges in assessing a newborn/infant's pain?
based on observed behavior; babies may respond differently to pain and interpretation of physical responses may be different in different ppl
2 negetive effects of childhood pain?
1. negative reactions to painful events
2. poor acceptance of health care interventions later in life
What areas of pediatric pain management need improvements?
1. collaboration of nurses and MD's
2. education of professionals
3. effective pain management
4. info about pain management of neonates/infants
5. testing of new analgesics especially in children
7 barriers to effective pain management in children?
1. belief in myths
2. knowledge deficits
3. inaccurate pain assessment
4. insufficient awareness of pain interventions
5. lack of confidence in pain measures
6. lack of communication with child/parents
7. personal attitudes/beliefs about pain
What are the 2 beliefs of parents and nurses that are most likely to interfere with adequate pain management in infants/children?
1. fear of respiratory depression
2. fear of addiction
T/F Due to the fact that neonaes have incomplete myelinization, they do not feel pain.
false, they have all structures required to feel pain even when they are premature
Can the nurse use previous experiences of a particular injury to predict the intensity of pain felt by a new pt with that injury? Why?
No, because the amount of pain experienced even with the same condition is individual.
Are children more susceptible to becoming addicted to pain medications?
What is the risk for respiratory depression when using narcotics with children?
There is no more risk than with adults, and it is very rare
What is the function of a pain management team?
1. pain management recommendations
2. education of healthcare members
3. train resource nurses in units
What is the purpose of a pain resource nurse in a unit of the hospital?
provide advice and support to colleagues on best practices in pain management
What 9 factors may affect pain in children?
1. type and duration of pain
2. developmental level
3. emotional status
4. previous experiences with pain
9. parental response to child's pain
Is it accurate to use changes in vital signs to assess infant pain?
How does the nurse assess pain in an infant/child that cannot verbally express the pain?
combination of behavioral and physiologic signs and a pain assessment tool
What should the nurse do if a child says there is no pain but appears to be in pain?
be gentle with them and ask them again because they may be afraid to admit the pain
How may children with chronic pain differ in their expression of pain from others?
They may not show physical signs of the pain and may not be able to accurately describe the intensity of the pain
How can questions about a child's ADL's help with pain assessment?
if the pain is interfering with ADL's it will indicate the duration and intensity of the pain
3 reasons older children may be afraid to report their pain?
1. fear of treatment/shots
2. may have been told to "be brave"
3. "say no to drugs"
How can nurses overcome barriers to pain management involving unfounded fears of parents and children?
4 ways that expression of pain may be different in different cultures?
1. nonverbal expressions of pain
2. words used for pain
4. descriptions of pain
4. rating of pain
Why may infants have lower pain thresholds than older children and adults?
their immature NS may not be able to modulate the pain experience
If an infant experiences rapid changes in behavioral state and sleep/activity patterns _____ is likely.
6 behaviors that serve as indicators of infant pain?
crying, fist clenching, grimacing, wrinkling of the forehead, fussiness, and restlessness
________is considered the most consistent cue available when judging pain in infants and children.
How may an infants cry when in pain be different from crying due to hunger or other things?
higher pitched, tense, and harsh
How is the physical response to pain different in neonates and older infants?
neonates have a total body response to pain and older infants have more purposeful movements to prevent/relieve the pain
How can the state of the infant directly before pain affect the response to pain?
response is greater when the infant is alert and awake than if it is asleep
What is a concern in pain management for neonates that are repeatedly exposed to pain?
They may not exhibit usual behavioral responses to pain
What is the risk of treating agitation of an infant as pain when it is not?
the source of the agitation remains untreated
Why is it important for nurses to use pain assessment tools?
evidence-based practice - they have been studied extensively
Toddler's response to pain?
cry longer than infant, verbally express pain, ask for parents, may try to stop a painful procedure or run from the nurse
3 signs of pain in a toddler?
1. generalized restlessness
2. guarding the site
3. touching the painful area
What physical expressions may a toddler have in response to pain?
facial expressions of anger and fear, avoid eye contact, look sad, regression to earlier behaviors
What can intensify the pain experience of preschoolers?
they are egocentric and cannot associate discomfort with a future positive outcome
At what age should a child be able to describe the location and intensity of pain?
At what age may a child be ale to localize the pain and point to the body part that hurts
older toddler and up
What may preschoolers believe about pain?
that it will magically go away and is a punishment,
What particular fear do preschoolers have regarding pain?
bodily mutilation especially of genitals
2 behavioral responses that may occur in response to pain in preschoolers?
At what age can children describe pain, relate it to a specific body part, and quantify pain intensity?
At what age do children begin to understand the need for painful procedures?
At what age may children appear to overreact to illness or injury? Why?
they fear body harm and have an awareness of death
What behaviors may indicate pain in school-aged children?
What reactions may they have to pain?
stiff body posture, withdrawal, may cry when alone
may procrastinate or bargain to get out of treatments and may regress
What may a school aged child do if they loose control when in pain and cry or act aggressively?
deny that the behavior occurred
At what age can a child think abstractly and understand cause and effect?
At what age can a child describe and quantify pain intensity and their feelings about pain and discuss strategies to control their pain?
Why may adolescents repress manifestations of pain?
because they are egocentric and think that others are focused on their behavior
Why do some adolescents not report pain?
they think that the nurse knows they are in pain and that they will be given pain meds when they need it even if they don't ask for it
What physical manifestations of pain may be observed in adolescents?
increased muscle tension, withdrawal, and decreased motor activity
What must be documented when using a pain assessment tool?
what tool was used
_______ is one of the first resources to assist in assessing the child's pain and response to interventions when the child is unable to express or quantify pain.
Physiologic changes (VS) are a more reliable indicator of ______ pain than ______ pain, but may also indicate some other problem unrelated to pain.
How do children benefit from use of a pain assessment tool?
gives them a simple and effective way to communicate pain
How should the nurse decide what assessment tool to use for pain?
should correspond to the child's developmental abilities
What pain assessment tool is reliable to use for preverbal and nonverbal children?
FLACC - face, legs, activity, cry, consolability
At what age can a child verbalize words for pain?
approx 18 months
At what age is cognitive ability sufficient for reporting the extent of pain?
3 to 4 years
Self-report tools are effective in children older than ____ years for pain assessment.
3 pain assessment tools that may be used for children preschool - school age?
the Oucher pain scale, the Poker Chip Tool, and FACES Pain Rating Scale
What pain assessment tool offers culturally diverse versions for AA, Asian, Canadian Indian or Hispanics?
the Oucher pain scale
Which pain assessment scale has been translated into 10 different languages?
the Wong-Baker ACES Pain Rating Scale
At what age can children understand concepts of order and number and use numeric rating scales, word-graphic rating scales, and visual analog scales?
What is it necessary to do when using a pain assessment tool to insure consistent assessment of pain?
use the same assessment tool each time
What may done during preprocedure or preoperative education for a child/family regarding the pain assessment tool?
teach the child how it works
What should the nurse do prior to assessing the pain/pain history of a child?
How is this information incorporated into the nursing careplan?
ask the child and family what word is used to indicate pain
it is used consistently with the child
5 pieces of information included in getting the pain history of a child?
1. child's past pain experiences
2. how the child reacts to pain
3. person the child tells about pain
4. how the parents know when the child is in pain
5. what works best to take away the child's pain
What instructions should the nurse give to a child that is using the FACES pain rating scale?
Tell them to choose the face that best describes their own pain
What are its 3 parts?
What age is it for?
3-part tool composed of body outline, an intensity scale, and a pin descriptor word list
8 - 17 year olds
CRIES pain scale
C - crying
R - requires O2 for Sao2 < 95%
I - increased vital signs
E - expression
S - sleepless
2 points for each
higher score = more pain
What age group is the CRIES pain scale for?
neonates - 6 montsh
COMFORT behavior scale?
6 categories are scored from 1-5 with a resulting score of 6 - 30 with higher score = greater pain
The FACES pain rating scale is for age ____ and up.
NRS pain rating scale?
What age group?
Numeric Rating Scale - pt asked to give a number that reflects pain level 0, 13, 46, or 710
age 9 and up
Oucher pain scale?
0-100 scale for older kids
6- picture photographic scale for young children
Poker Chip Tool?
4 poker chips represent hurt with 1 being the least and 4 being the most
4 - 12 years
Visual Analogue Scale - 10 cm line with one end representing no pain and the opposite end the worst pain
7-18 years old
Pain management for children is "multimodal" including a combination of ______, _____, and ______.
1. control of environment (peaceful)
2. pharmacological treatment
3. non-pharmacological treatment
What information should be provided for parents about pain management of their child in the home?
1. give them a pain assessment tool
2. dose, route, and schedule for pain meds
3. intervetions that are appropriate
4. should notify provider if pain management is ineffective
5. contact info for provider
Benefits of allowing parents to perform non-pharmacological comfort measures for pain?
child is more comforted by parent and parent feels like they are involved in care
_____ is an effective adjuvant for pain management that works by refocusing the child's attention from pain to something else.
If a child is effective at using distraction how could this effect the nurse's pain assessment?
the nurse could think they are not in pain
Examples of distraction?
blowing bubbles, listening to music, reading, video, board games, doing spelling words, allowing the child to participate in treatments/hold equipment
Examples of non-pharmacological interventions to pain?
distraction, regulated breathing, guided imagery, biofeedback, progressive muscle relaxation, hypnosis, acupuncture, topical heating/cooling,massage, TENS (small amnt of electricity to skin),
Pain management experience and research have taught that _______ drug therapy is more effective than a single analgesic.
4 characteristics necessary for the analgesic used?
1. prompt onset of action
2. predictable duration of action
3. manageable side effects
4. appropriate reversal agent
How should the route for analgesia be chosen?
least invasive route that provides optimum analgesia should always be chosen
The _____ route of meds should be avoided because it disturbs children.
6 disadvantages to IM analgesia in children?
1. fear of shots
2. fluctuations in tissue absorption lead to fluctuating analgesic effect
3. kids may not have suitable sites for the injection
4. some meds can damage tissues and nerves
5. shorter duration of action than oral
6. contraindicated in kids with low platelet counts and bleeding disorders
patient controlled analgesia
How is amount of meds that can be administered regulated with a PCA pump?
there is a lock out period after each dose and a max amount that can be given within a certain time period
What is the procedure for hanging meds for a PCA pump?
1. check that all doses are correct for age
2. 2 RN must check the ba or syringe
3. after the PCA pump is programmed it must be double-checked by another RN
What do the assessments of a patient with a PCA pump include?
1. effectiveness of pain meds
2. equipment functioning
3. signs of overmedication and side effects
What is the main concern for a pt on PCA?
respiratory depression due to overmedication
How often should the nurse get VS for a child on PCA?
q 2 to 4 h
Monitoring that may be required for PCA pt?
constant pulse ox, cardiac, respiratory monitoring
RR q 1 h
3 items that should be readily available for a PCA pt?
2. a bag-valve mask
3. IV naloxone (narcan)
narcan - drug given to reverse the effects and respiratory depression of analgesics
How is naloxone administered? Why?
IV slowly until it is first noted that respiratory depression is reversed because if it is given too fast it can cause cardiac arrest
How often may naloxone need to be repeated? Why?
q 30 to 60 minutes
has a short half-life
When should pain assessments be performed when a pt is using PCA?
q 1 to 4 h and with each bolus dose
What documentation is required with PCA?
q h must document # of bolus doses and # of bolus attempts by the child
q 1 to 4 h must document total mg dosages of the med received on MAR
Most hospitals permit the use of PCA by children age _____ years.
5 to 7
How may a PCA be used for children who are unable to administer their own doses?
staff or family by proxy
How is PCA by proxy regulated?
What are TJC guidelines for PCA?
1. should have strict guidelines for selecting/educating nurse/ family to admin med
2. oral and written instructions on when child does/does not need bolus
3. selecting single nurse/family member who will consistently be there to assess effectiveness of treatement
4. documenting teaching and supervision of the person giving the AACA
authorized agent-controlled analgesia
What are topical anesthetic agents used for?
to numb area before an invasive procedure
Some topical anesthetics used for children?
EMLA - lidocaine prilocaine 5% cream
Ametop - 4% amethocaine gel
LMX 4 or LMX5 - liposomal lidocaine 4 - 5%
Synera patch - 70mg lidocane/70 mg tetracaine
When would topical anesthetic agent be contraindicated?
if skin is not intact
Generally, an anesthetic cream is placed on the skin at the procedure site for _____ time and provides a numbing effect for _____hours
30min - 2.5 hours
1 to 2 hours
What should parents be advised to do when applying an anesthetic cream?
Important consideration when using a topical cream in young children?
need to be monitored so they don't rub in eyes/ears or try to eat it
What is the main side effect with any topical anesthetic cream?
When does it subside?
skin redness or blanching
a few hours
What should the nurse do if burning, swelling, itching, or a rash occur at the site of a topical anesthetic?
remove it immediately
What is used to provide immediate numbing of the skin for urgent procedures?
How are vapocoolant sprays administered?
sprayed directly on skin at the site or on a steril cotton ball and applied for 15 seconds
When is the onset of action of a vapocoolant spray and how long does the numbing effect last?
lidocaine hcl 2%/1:100,000 epi topical solution that is delivered through an electrode patch that uses a mild electric current to push the meds into the skin to a depth of 10 mm
a mild electric shock
J-Tip jet device
delivers 1% buffered lidocaine into the skin at a depth of 5 to 8 mm via a carbon dioxide gas-driven pluger
2 needless systems of topical anesthetic?
Where must they be used?
Numby Stuff, J-Tip
must be used in a healthcare setting
How do nurses act a s pt advocates in the selection of pain interventions?
encourage parents, older children, and adolescents to participate in selection of interventions for their pain
______ is the most commonly used analgesic for mild to moderate pain and the drug of choice for treating children's fevers in the US.
Is the use of tylenol safe in neonates?
What GI side effects are caused by tylenol?
What dangerous side effect can tylenol have especially if an overdose occurs
What may occur if a child is taking tylenol along with other meds for colds?
overdose of tylenol r/t tylenol included in the cold meds
Action of NSAIDS?
reduce pain, fever, and inflammation by inhibiting prostaglandins
What NSAIDS are commonly used to treat mild to moderate pain in children?
ketorolac - toradol
What type of pains are NSAIDS preferred for?
bone and inflammatory pain (injuries, arthritis -like conditions, some cancers)
Why is aspirin not recommended as an anti-inflammatory drug in children?
association with Reye Syndrome
acute brain damage and and problems with liver functioning of unknown cause
natural or synthetic opium derivatives that bind to CNS opioid receptors and control pain by depressing pain impulse transmission
What type of pain are opioids used for?
moderate - severe acute and chronic pain
7 opiods commonly used for children?
codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone
Why should the nurse call med an opioid and not a narcotic?
narcotic is associated with illegal drug use and may deter the pt from taking it
What is the preferred route for opioids in children?
What 2 opioids are available in SR forms?
How long do their effects last?
How is breakthrough pain handled?
morphine and oxycodone
12 to 24 hours
supplemented with a short-acting form of these anlgesics for break throug pain
How is medication administered if po meds are contraindicated?
What meds are used?
IV or subQ
morphine, fentanyl, hydromorphone, methadone
When should IM route by used for opioid admin in children? Why?
only when absolutely necessary because of children's fear of shots
What is the goal regarding the first dose of an opioid?
How is the dose determined?
control pain as rapidly as possible
chid's body weight, physiologic development, and situation
How should subsequent doses of opioid meds be determined?
by child's response
point where adding more of a medication does not produce any more effect
8 common side effects of opioid analgesics?
sedation, respiratory depression, constipation, pruritis, nausea, vomiting, cough suppression, urinary retention
What 3 side effects of opioids usually resolve within 1 to 3 days?
What is done in the meantime?
administer antiemetics and antipruritics
_____ is the most commonly given oral opioid for moderate pain.
In what forms is it available?
with either acetaminophen or ibuprofen in tablet or liquid form
2 opiods given for moderate pain other than hydrocodone?
What forms are they available in?
oxycodone and codeine
single agents or combined with acetaminophen
oxycodone is available in SR form
______ is the preferred opioid for children
When does morphine reach its peak effect after IV and oral admin?
IV - 10 - 20 minutes
PO - 1 h
Morphine can produce _____ along with analgesia.
Max respiratory depression with a morphine dose occurs _____ mutes after IV admin.
What should be available when a pt is receiving morphine in case of respiratory depression?
What is the normal order for morphine like?
may titrate prn within a particular range of doses
What opioid is very similar to morphine, but is 6X more potent?
When is hydromorphone used?
as a first-line opioid for moderate to severe pain or as an alternative to morphine when intolerable side effects occur
_____ has a shorter duration of action than morphine and is 50 - 100 times more potent.
Why does fentanyl produce less pruritis than other opioids?
less histamine is released when it is used
The short duration of fentanyl makes it useful in what situations?
brief, severely painful procedure is being performed
What is necessary when using fentanyl?
a closely monitored setting
What is the fentanyl patch used for?
Who is it usually given to?
Which opioid is metabolized very slowly and has a prolonged duration of action?
What are the routes available for methadone?
What is an important consideration in dosing it?
How does it compare to the potency of morphine?
po and IV
because it is slowly absorbed titration requires diligent pain assessment
equal in potency to morphine
Which opioid should be used only for short-term pain control in children who have shown an allergy or intolerance to other opioids?
How does the duration of meperidine compare to morphine/
What are some side effects of meperidine?
convulsions, dysporia, hallucinations, and agitation
What is procedural sedation?
controlled state of depressed consciousness where pt controls own airway and breathing and is able to respond, retains protective reflexes like coughing
3 types of procedural sedation?
minimum, moderate/conscious sedation, deep
How is procedural sedation usually achieved?
IV admin of a sedative-hypnotic, an analgesic, or a dissociative medication of a combination of these
other routes may also be used
3 sedative hypnotic drugs?
Dissociative med used for procedural sedation?
What is versed/midazolam frequently used for?
sedation and induction of general anesthesia
3 reasons versed/midazolam is used for procedural sedation?
1. minimal SE
2. short- acting
3. can be used without IV access
Why should versed/midazolam be given with an opioid for painful procedures?
it has no analgesic effect
What healthcare professionals must be present for children receiving procedural sedation?
those with advanced skills in airway management
physicians, anesthesiologists, or CRNA
What is the nurse's role when a pt is given procedural anesthesia?
frequent assessment and documentation of VS, O2 sat, capnography, and LOC during and after procedural sedation
concentration of exhaled CO2
How is epidural analgesia administered?
What meds are used?
through epidural catheter inserted into the epidural space of spinal canal and secured to the child's back with an occlusive dressing
usually an opioid, a local anesthetic, or both
Why are smaller doses required with epidural analgesia?
How does this benefit the pt?
med is administered directly to nerves that ransmit pain
fewer side effects
Why would epidural analgesia be used in a child?
following abd, anal, and genitourinary surgeries, open-heart and thoracic surgeries, and orthopedic surgeries of the lower limbs
How is a child recieving epidural analgesics monitored?
attached to a continuous cardiac monitor and pulse ox
should be assessed for adequate pain relief, presence of adverse effects and complications r/t the epidural catheter placement
What adverse effect is of particular concern in children with an epidural analgesic?
6 side effects of epidural analgesia?
constipation, N, V, urinary retention, motor block, and sensory block
During epidural analgesia, a child's dermatome (level of sensory blockade)should be checked q ____ h.
When a child is getting epidural analgesia _____ must be inspected frequently.
What findings should be reported?
catheter insertion site
displacement, bleeding, leakage of CSF, hematoma
acetaminophen dosages and routes?
po or rectal suppository - 10-15mg/kg/dose q 4 to 6 h (6-8 h for neonates)
acetaminophen maximum dose in 24 h?
90/mg/kg/24h not to exceed 4000 mg/day