Chapter 7: Pain assessment and management in children

1. Chapter 7: Pain assessment and management in children Laura Salisbury RN, MSN/Ed.

2. Pain Assessment • Distress behaviors: What are these? • Developmental characteristics of pain response (see box 7-1, p. 159) • Three types of measures to assess child’s pain: • Behavioral • Physiologic • Self-report When are these measures accurate? What makes them inaccurate?

3. Pain rating scales for Children • FACES • FLACC • OUCHER • Poker chip tool • Word-graphic rating scale • Numeric scale • VAS (visual analog scale) • Color tool

4. Pain in Neonates • Difficult to assess • Can only be based on physiologic and behavioral responses • Assessment tools: • CRIES • PIPP (Premature Infant Pain Profile) • NPASS (Neonatal Pain, Agitation, and Sedation Scale)

5. Pain in Children with Communication and Cognitive Impairment • At greater risk for under treatment of pain • Primary caregiver important source of information • Pain measurement tools: • Non-communicating Children’s Pain Checklist • PICIC (Pain Indicator for Communicatively Impaired Children)

6. Pain in Children with Communication and Cognitive Impairment • Cultural issues: what may affect cultural appropriateness of pain assessment? • Children with Chronic Illness and Complex Pain • Important components of assessment: what are they?

7. Pain Management • Nonpharmacologic management • Virtual reality • Containment/swaddling/tucking • Nonnutritive sucking/with or without sucrose • Kangaroo care • Complementary pain medicine

8. Pharmacologic management • Based on weight until 50 kg (110 lbs) • Acetaminophen (15 mg/kg) • NSAIDS (10 mg/kg) • Opioids • Adjuvants

9. Routes and Methods of Analgesic Drug Administration • Oral • PCA: Patient-controlled/nurse-parent controlled • Transmucosal • IV/Sub-Q • Intramuscular • Intranasal • Intradermal • Transdermal/topical • EMLA • LAT • Numby Stuff • Epidural/Intrathecal • Rectal • Regional nerve block • Inhalation

10. Monitoring and treatment of side effects from opioids • Respiratory depression • Constipation • Pruritis • Nausea/vomiting • Sedation • Physical dependence • Withdrawal • Tolerance • Addiction (psychologic dependence)

11. Evaluation of therapy • Possible effects of pain in infancy/childhood • Painful and Invasive Procedures/Postoperative pain • Use of nitrous oxide • Surgery and traumatic injury generate a catabolic state • Preemptive analgesia • Multimodal analgesia

12. Recurrent headaches in children • Recurrent abdominal pain in children • Cancer pain in children • Peripheral neuropathy • End-of-life pain and sedation

13. Chapter 22: Pediatric variations of Nursing Interventions Laura Salisbury RN, MSN/Ed.

14. Informed Consent • Patient assent • When is treatment given without parental consent?

15. Preparing children for procedures • Doing the procedure • Treatment room • Be confident • Use distraction • OK to express feelings; OK to cry • After procedure: Allow venting, give positive reinforcement

16. Surgical Procedures • Surgical Procedures • Advantages vs. disadvantages of keeping parent with child until anesthesia • Preoperative sedation: necessary? • Fasting before hand? (Table 22-1, p. 696) • Postoperative care • Symptoms of malignant hyperthermia; how is it treated?

17. General Hygiene and Care • See Skin Care guidelines, • box on p. 700 • What is epidermal stripping? • How do you encourage nutrition? • Fluid intake?

18. Controlling increased temperature • Fever vs. hyperthermia: what is the difference? • Fever: antipyretic FIRST, then cooling measures: don’t allow shivering • Antipyretics do not prevent febrile seizures • Hyperthermia: Antipyretics will not work • Concerning signs: See box p. 704

19. Safety • Accurate identification: how? • Prevent falls: how? • Infection control: KNOW BOX 22-5 p. 707: types of precautions and patients requiring them • The most critical infection control practice is: • How should pediatric patients be safely transported?

20. Restraints • Behavioral: Rarely used in pediatrics • Medical-surgical: when are they used? What precautions should be taken? • Temporary restraint (procedural): what is therapeutic holding? • Mummy restraint, swaddle, jacket restraint, arm/leg restraints, elbow restraints • How are children positioned for an LP?

21. Specimen collection • Urine: how? Getting out of disposable diaper (see “FYI” p. 712) • What is suprapubic aspiration? When is it used? • Stool: How? • Blood • Out of saline lock • Arterial: do Allen test first • Infant heel puncture: • how do you do it safely? • Where to you puncture • Sputum: Nasal washing

22. Administration of Medications • Oral route: measure accurately! Do not mix meds with bottle; know when you can crush pills • Use of an oral syringe to get med into an infant • Intramuscular: use vastuslateralis in the infant; can use ventrogluteal all ages; deltoid in older children, when small amount of med (How much can be given in a single shot in each site?) • See guidelines box, p. 721

23. Administration of Medications • IV devices • Saline lock: short term • Central access: • Non-tunneled catheters • PICC lines • Rectal • Rectum needs to be empty; can be difficult to get the right dose • NG/OG/Gastrostomy: see guidelines p. 730 • Eye drops: careful not to contaminate

24. Fluid Balance • Maintaining fluid balance • 1 gram wet diaper weight=1 mL urine • Dealing with children who are NPO/fluid restricted • Parenteral fluid • Rehydration methods • ORS • IV Fluid

25. Site Selection • Avoid dominant hand; avoid foot/leg in children who are walking • When rapid IV access needed, can’t get IV site: Intraosseous (runs just like an IV) • Secure the site…but allow for circulation assessment distally; watch for infiltration • How do you remove tape? • What is the difference between infiltration and extravasation?

26. Oxygen Therapy • Hood • Nasal cannula • Oxygen tent • Mask not usually tolerated • Oxygen toxicity: retina of preterm infants; lungs damaged with excessive use • What is oxygen-induced carbon dioxide narcosis? • Pulse oximetry: Change site frequently to avoid burns, necrosis

27. Respiratory treatments • Aerosol therapy • Handheld nebulizers • MDI: use a spacer • Postural drainage: what is it? When used? • Chest physical therapy: What is it? When used?

28. Artificial Ventilation • Nasotrachealintubation preferred over endotracheal when possible • Only uncuffed endotracheal tubes for children less than age 8 • Always humidify air/gas being delivered directly to trachea • Tracheostomies: What do we watch for? • Suctioning: NO MORE than 5 seconds: hyperventilate with 100% oxygen pre and post; no more than 3 passes at a time; only as often as needed • What if tube is totally occluded or it comes out? What to do?

29. Alternative Feeding • Gavage feeding • Flows in by gravity • Give infants something to suck on • Gastrostomy tubes (G-tubes): may flow in by gravity or be put on pump • Nasoduodenal, nasojejunal: When are these used? What tells us that it may be in the wrong place? • Always verify placement by X-ray before first use • TPN: Control risk of sepsis, watch infusion rate, assess patient’s tolerance

30. Enemas and Ostomies • Use isotonic solutions; • Don’t use Fleet enema (not even the pediatric Fleet!) • Particularly distressing for preschool child • Children can be taught to manage own ostomy appliance; adolescents especially disturbed by ostomy