pain assessment.ppt

Methods of Pain assessment in children- notes for Nursing students

1. Pediatric Pain
Assessment

2. Pain Assessment in Children
“Pain is whatever the
patient says it is.”

3. Definition of pain
•“Pain is whatever the experiencing
person says it is, existing wherever and
whenever he or she says it does.”
(McCaffery)
•Chronic Pain: Pain that has outlived it’s
usefulness
•Acute Pain: An adaptive, beneficial
response necessary for the
preservation of tissue integrity

4. 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.”

5. Myths About Pain
Myths About Pain
Neonates do not experience pain
Children have no memory of pain
There is a correct amount of pain for
a given injury
Children can easily become addicted
to narcotics
Narcotics can easily cause respiratory
depression

6. Facts About Children & Pain
Infants do feel pain
Children do not tolerate
pain better than adults
Children can tell you
where they hurt
Children do not always
tell the truth about pain

7. Facts About Children & Pain
Children do not become
accustomed to pain or
painful procedures
Behavioral manifestations
of pain may not reflect
pain intensity
Narcotics are no more
dangerous for children
than adults

8. Children Do Not Tolerate
Pain Better Than Adults
•Children’s tolerance to pain
actually INCREASES with
age.

9. Children Can Tell You
Where They Hurt
•Children beyond infancy can
accurately point to the body
area or mark the painful site
on a drawing; children as
young as three years can use
pain scales.

10. Children Do Not Always Tell
The Truth About Pain
•Children may not admit having
pain to avoid an injection,
because of constant pain, or
because they believe others
know how they are feeling.

11. Children Do Not Become
Accustomed To Pain or
Painful Procedures
•Children often demonstrate
INCREASED behavioral signs
of discomfort with repeated
painful procedures.

12. Behavioral Manifestations
of Pain May Not Reflect
Pain Intensity
Children’s developmental level,
coping abilities, and
temperament, such as activity
level and intensity of reaction
to pain, influence pain behavior.

13. QUESTT…..
•Question the patient
•Use pain rating scale
•Evaluate behavior and physiologic
signs
•Secure family’s involvement
•Take cause of pain into account
•Take action and assess effectiveness
Multidimensional Model of Pain Assessment

14. Multidimensional Model of Pain Assessment
(QUESTT)
T

15. Question the Child
Verbal Indications of Pain
•Much less common than in adults
•May not understand term, such as
“pain”
•May speak globally, such as “I
don’t feel good”
•May deny pain for fear of injection
•Cries, screams, groans, moans

16. •Use a variety of words to
describe pain, such as owie,
boo-boo, ouch, hurt,
•Know words in other languages
Question the Child, cont.

17. Have Child Locate Pain by:
•Marking body parts on a
human figure drawing
•Point to area with one finger
on self, doll, stuffed animal
•Point to “where mommy or
daddy would put a bandage”

18. Use diagram to have child
locate pain

19. Burn patient’s drawing

20. Use Pain Rating Scale
•In 2001 Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO) published
Pain Standards
•One of the standards is to make
pain rating the 5
th
vital sign.

21. Use Pain Rating Scale, cont.
•Select a scale that is suitable for
the child’s age, abilities, and
preferences
•Teach child to use scale before pain
is expected, such as preoperatively
•Use same scale with child each time
pain is assessed
•Ask child about acceptable or
functionalpain level

22. Pain Assessment
•Location
•Characteristics
•Onset / Duration
•Frequency
•Quality
•Intensity / Severity
•Precipitating Factors

25. Assessment Tools
•Self-Report “The Gold Standard”
•Observational Scales
•Physiologic Parameters
•Parent Report
•Nurse Report

26. Self-Report
•Description of Pain
-type of pain
-intensity of pain
•Pain Scale Ratings

27. Observations
•Vocalization / verbalization
•Facial Expression
•Body Language
•Emotional State

28. Physiologic Parameters
•Heart rate
•Respiratory rate
•Blood pressure
•HR, RR, BP
•shallow respirations
•vagal nerve tone (shrill cry)
•pallor or flushing
•diaphoresis, palmar sweating
•O2 saturation
•EEG changes

29. Parent Vs. Nurse Report
•Varying results in studies comparing
parent, nurse, and self-report
•May be especially useful in
cognitively impaired children

30. Special Situations
•Cognitively impaired
•Cerebral palsy with normal cognitive
level
•Hearing or vision impaired
•Non-English speaking
•Intubated / paralyzed patients

31. Developmental Factors
•Newborns and small children unable to
give self-report
•However, avoidance behavior has been
shown by at least 6 months of age
•Consistency of facial and cry response
has been shown in neonates and infants
•Children 3-5 yrsare able to use some
self-report measures, localize pain

32. Assessment in Neonates
•Neonatal Infant Pain Scale (NIPS)
•Parent Report
•Nurse Report
•Physiologic Measures

35. Assessment in Infants and
Children < 3 Years
•OPS
•CHEOPS
•Parent Report
•Nurse Report
•Physiologic Measures

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

38. Assessment in Children 3-6 Yrs
•Faces Scale
•OucherScale
•Poker Chip Tool
•Visual Analogue Scale (VAS)
•Observation Tools
•Parent Report
•Nurse Report

39. FACES Rating Scale

40. •Make sure the child has an understanding of number
concepts and then teach the childto use the scale.
•Point to each face and use the words under the picture to
describe the amount of pain the child feels.
•Then ask the child to select the face that comes closest to
the amount of pain felt.

41. Faces Pain Scale
•Make sure the child has an understanding of number
concepts and then teach the childto use the scale.
•Point to each face and use the words under the
picture to describe the amount of pain the child
feels.
•Then ask the child to select the face that comes
closest to the amount of pain felt.

42. Numerical Rating Scale

43. Assessment in Children > 6-7 Yrs
•Self-Report
-VAS
-Numerical Ranking Scale
•Observational Scales
•Parent Report
•Nurse Report

45. Pain Indicator for Communicatively
Impaired Children (PICIC)
Most common cues identified by 67
parents:
•Screwed up or distressed looking face
•Crying with or without tears
•Screaming, yelling, groaning, moaning
•Stiff or tense body
•Difficult to comfort or console
•Flinches or moves away if touched

46. Observe for Improvement in Behavior
Following an Analgesic

47. Observe for Improvement in Behavior
Following an Analgesic

48. Secure Family’s Involvement
•Take pain history before pain is
expected, such as on admission
to hospital or preoperatively
•Involve family in recording
response to pain relief
measures

49. Secure Parents’ Involvement,cont.

50. Consequences of Pain
•Cardiovascular and respiratory changes
–Tachypnea, increased B/P and heart rate
–Inadequate lung expansion, decreased arterial saturation
–Inadequate cough
•Neurologic changes
–Fight /flight response-Tachycardia, insomnia, glucose
•Metabolic changes
–Increased fluid and electrolyte losses
•Immune system changes
–Depression of immune system with increase in risk for
infection
•Gastrointestinal changes
–Increased intestinal secretions, prone to ileus

51. Pain Management
•The presence of
the parent is an
important part of
pain management.
Children often feel
more secure telling
their parents about
their pain and
anxiety

52. Non-pharmacological Pain Management
•Behavioral distraction
•Assorted visuals
•Breathing techniques
•Comfort measure
–Repositioning, holding
–Touching, massaging
–Warm or cold compresses
•Diversionaltalk
•Guided imagery
•Biofeedback
•Progressive muscle relaxation

53. Pharmacologic Interventions
for Pain
•Analgesics
–Patient-controlled analgesia
–Topical anesthetic cream
•Non-steroidal anti-inflammatory
drugs
•Opioids
•Conscious sedation
•Epidural analgesia

54. Administering Analgesics to
Children
•The preferred routes are intravenous
or oral.
•Infants and children receiving IV and
epidural opioids should be monitored
by pulse oximetry.
•If respiratory depression occurs with
opioid use, naloxone hydrochloride
should be used for reversal when
oxygen and stimulation of the child
are ineffective.

55. Nursing Interventions
•When painful procedures
are planned, use EMLA
cream to anesthetize the
skin wherethe painful stick
will be made.
•Procedure :
–Apply a thick layer of cream
over intact skin.
–Cover the cream with a
transparent adhesive
dressing, sealing all the sides.
•The cream anesthetizes the
dermal surface in 45 to 60 min.

56. Take Cause of Pain into
Account
•Use common sense and
logic.
•Realize that for a an
infant and small child,
punctures are
proportionally larger on
their tiny bodies.

57. The only reason to assess pain is
TO TAKE ACTION TO RELIEVE
PAIN.
After intervention, assess child’s
response to pain relief measures.
•Determine timing of assessment
based on expected onset and peak
effect of intervention:
•IV analgesic: assess after 5
minutes and 15 minutes
Take action and assess
effectiveness

58. The Golden Rule
What is painful to an adult is
painful to an infant and
child unless proven
otherwise.

59. “Golden Rule” of Pain
Assessment
•Don’t forget to ask
the patient !!!

60. You be the one to say:
•The pain
Stops
here!!!!!!!!!