Pain assessment and management for the children

1. Pain assessment and management for the children Definition P288 Outdated beliefs about pain in children P288 影響疼痛反應的因素 (補) Clinical manifestations of pain P289 Pain assessment of the children P290 Medical management of pain P296 Nursing management of pain P299 Nursing problems P300, 301

2. Definition P288 • 「Pain exists when the patient says it does」(McCaffery & Pasero, 1999). P288第1段 • Acute pain 第2段第2 行 • is sudden pain of short duration that may be associated with a single event. • Chronic pain • is persistent pain lasting longer than 6 months that is generally associated with a prolonged disease process such as JRA.

3. Outdated beliefs about pain in childrenP289 table9-1 • Neonates and infants do feel and remember pain. P288 第2段第2行 • By 6months of age, children demonstrate anticipatory fear of pain when taken to a location where they once experienced pain. • They are afraid that the injection to relieve pain will hurt more than the pain already does.

4. *影響疼痛反應的因素 • 文化背景 • 發展程度 （P293 Table 9-5） • 父母的態度 • 住院及手術前的衛教 • 分離的焦慮感 • 止痛劑 • 護理人員的態度 • 性別 • 患童本身之因素 （P293 Table 9-6） 認知 行為 情緒 生理

5. Pain indicators • Physiologic indicators P289 • Behavioral indicators P289 • Consequences of painP290 Table 9-2

6. Physiologic indicators P289 • Acute pain • tachycardia 、tachypnea 、hypertension 、 pupil dilation 、pallor 、perspiration • Chronic pain • Physiologic adaptation so normal.

7. Behavioral indicators P289 • Restless and agitated or hyperalert and vigilant. • Short attention span. • Irritability. • Facial grimacing ,biting or pursing lips. P290（Fig. 9-2） • Posturing（guarding a painful joint by avoiding movement）, remaining immobile, or protecting the painful area. • Anorexia • Lethargy • Sleep disturbances

8. Consequences of painP290 Table 9-2 • Shallow breaths and suppresses coughing • Delay the return of normal gastric and bowel functions • Anorexia respiratory complications delay the healing process

9. Keep the following questions in mind: P291 Pain assessment of the children P290 • What is happening in tissues that might cause pain? • What external events could be causing pain? • Are there any indicators of pain? • How is the child responding emotionally? • How does the child or parent rate the pain?

10. Pain assessment of the children Q : Question the child ----pain history291 Table 9-3 U : Use a pain rating scale（P294& P295 Table 9-7、9-8） E : Evaluate behavioral and physiologic changes P292 table 9-4 & P289 Clinical manifestations of pain S : Secure parents’ involvement T : Take cause and influences of pain into account T : Take action and evaluate results

11. Use a pain rating scale P294& P295 Table 9-7、9-8 • NIPS （Neonatal Infant Pain Scale） : 6weeks after birth ; include facial expression、cry 、breathing patterns 、arm movements 、leg movements 、state of arousal （table7-8） • CHEOPS（Children’s Hospital of Eastern Ontario Pain Scale） : 1-7 years • Eland Color Tool : 4-9 years • Oucher Scale • Poker Chip Scale • Faces Pain Scale • Numeric Pain Scale • Pediatric Pain Questionaire

12. The adolescent and Pediatric Pain Tool (APPT ): 8-17 years (補) 1.These words that describe your pain 感覺的 情感的 評價的 無法確認 3.Color in the area on these drawings to show where you have pain. Make the marks as big or small as the place where the pain is. 2.Mark on the line No little medium large Worse

13. * Medical management of pain • Right drugP296 • Right dosage: body weight P297 Table 9-9, 9-10 • Right time P298 • Right route P298 • Observe for side effects (補) • Use supportive statements when administering analgesics(補)

14. Drug P296 • Opioids: morphine, codeine P296 Table 9-9 • Sedation, nausea, vomiting, constipation, itchingP297第2段第1行 • Respiratory depression, CV collapse, and addiction • Nonsteroidal anti-inflammatory drugs P298 Table 9-10 • Aspirin, acetaminophenP297第1段第1行 • Mild to moderate pain and chronic pain第2行 • Bone, inflammatory, and rheumatoid第3行 • Combination with an opioid • Conscious sedation P305最後1段& Table 9-13 • Midazolam, fentanyl, DPT

15. Right time • ATC （around the clock）P298第1段第2行 • Continuous-infusion analgesia 第2段第1行 • Scheduled (every 3-4 hours)第3行 • Prn. （as-needed）第5行

16. Right route • Preferred routes of administration • IV, local nerve block, oral P298. 第1段最後1行 • PCA • IV＋Epidural P298第3段第1行 • the first 48 hours after surgery. 第4行 • for children 5years and older. 第5行 • Subcutaneously（lidocaine）P305第3段第2行 • Skin（EMLA）P305第4段

17. Nursing management of pain P299 • Pharmaclogic intervention P301 • Nonpharmacologic management of pain P303

18. Pharmaclogic intervention P301 • PCA: monitor the flow rate and the site for infiltration. P301最後1段 • Naloxone may be used to treat respiratory depression caused by an opioid drug. • Monitor vital signs & check for other side effects. P302第1段 • Monitor the child for tingling of fingers or toes. 第2段 • Evaluate the level of pain. 第3段 • Sleep does not always indicate pain control.倒數第5行 • Become an advocate. 第4段

19. * Nonpharmacologic management of pain P303 • Parental involvement • Distraction • Cutaneous stimulation • Electroanalgesia • Relaxation techniques • Hypnosis • Guided imagery • Positive self-talk • Thought stopping • Behavioral contracting • Application of heat and cold

20. Nursing problemsP300, 301 • Pain / acute & chronic • Sleep pattern disturbance related to inadequate pain control • Knowledge deficit related to self-management of pain control • Inability to Sustain Spontaneous Ventilation：potential for opioid overdose • Constipation：potential for side effect of the pain medication and limited activity • Anxiety related to anticipation of a pain recurrent（補）