Fears of Bodily Injury and Pain

1. Fears of Bodily Injury and Pain • Common fears among children • May persist into adulthood and result in avoidance of needed care

2. Infant’s Response to Pain • Generalized response of rigidity, thrashing • Loud crying • Facial expressions of pain (grimace) • No understanding of relationship between stimuli and subsequent pain • Withdrawal from painful stimuli • Loud crying • Facial grimace • Physical resistance

3. Young Child’s Response to Pain • Loud crying, screaming, kicking, biting, spitting, trying to grab equipment or push away stimulus • Verbalizations: “Ow”, “Ouch”, “It hurts”. May also be verbally abusive and even curse • Toddlers may react to all procedures negatively whether painful or not • Toddlers can localize pain by pointing to it, but cannot describe it • Preschoolers have a great fear of mutilation and of “insides leaking out” • Preschoolers can localize pain and can describe severity by using Faces Pain Scale

4. School-Age Child’s Response to Pain • Stalling behavior (“wait a minute”) • Muscle rigidity, clenching teeth or fists • May use all behaviors of young child • May try to act brave; “grin and bear it” • May be more concerned with disfigurement or death than with pain itself • Psychosomatic complaints may be related to school or home problems • Can describe pain much like an adult

5. Adolescent • Less vocal protest, less motor activity • Increased muscle tension and body control • More verbalizations (“it hurts”, “you’re hurting me”) • May be more fearful of disability, disfigurement especially if it may cause physical changes • Psychosomatic complaints may be related to home or school problems, or initial sexual relationship • Usually describes pain as adult would

6. Preventing or Minimizing Fear of Bodily Injury and Pain • Prepare child for pain if developmentally ready • Give choices if possible • Allow child to express pain • Reward bravery • Ask child for his perception of illness or procedure, then dispel myths • Proper pain management, both pharmacological and nonpharmacological

7. Pain Facts and Fallacies (Box 44-10, p. 1316) • FALLACY: Infants do not feel pain • FACT: Children are undertreated for pain • FALLACY: Analgesia should be withheld because it may cause respiratory depression in children • FACT: Analgesia is withheld for fear the child becoming addicted • See Evidence-Based Practice p. 1315

8. Principles of Pain Assessment in Children: QUEST • Question the child—are you hurting? (may deny for fear of shot) Where? • Use a pain rating scale appropriate to age • Evaluate behavioral and physiologic changes • Secure parent’s involvement • Take action and evaluate results-oral meds are preferred, but IV is more predictable

9. Pain Scales • FACES pain rating scale • Numeric scale • FLACC scale • Facial expression • Legs (normal relaxed, tense, kicking, drawn up) • Activity (quiet, squirming, arched, jerking, etc) • Cry (none, moaning, whimpering, scream, sob) • Consolability (content, easy or difficult to console)

10. Nonpharmacologic Interventions • Based on age • Swaddling, pacifier, holding, rocking • Distraction • Relaxation, guided imagery • Cutaneous stimulation

11. Anesthetics & Analgesics • Major advancement for atraumatic care • EMLA (must be applied to skin approx one hour before injection) • Lidocaine for IV and IM sticks—need MD approval • Non-opioid—acetaminophen, NSAIDS • Opioid—morphine, fentanyl • Sedatives—midazolam, chloral hydrate