Transcript Pain Management in Children

Essentials of
Pediatric Nursing
Chapter 36: Pain Management in
Children
Nurses who Make a Difference
Managing a Child’s Pain
• Let’s watch this video about managing pain in
children – it will make you proud to be a
nurse!
• http://www.youtube.com/watch?v=HXJhLT2jUw&feature=related
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Types
of
Pain
Classification by duration
– Acute pain: alerts us to a problem, lasts a few days
– Chronic pain: lasts past expected point of healing for injured tissue. Previous
defined as lasting longer than 3-6 months
• Classification by etiology
– Nociceptive: from noxious stimuli of A-delta or C fibers
– Neuropathic: due to malfunction of peripheral or central nervous system
• Classification by source or location
– Somatic pain: develops in the tissues (cutaneous tissue)
• Superficial
• deep
– Visceral pain: develops within organs (heart, lungs, GI, GB, kidneys, or bladder)
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Factors Influencing Pain
Age and gender
Cognitive level
Temperament
Previous pain experiences
Family and culture
Situational factors
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Developmental Considerations
Infant
Toddlers
Preschoolers
School age
Adolescents
Another site about Pain in Children
Example of a reliable site to find information on
pain in children. Use as a resource when
teaching children and parents.
• http://www.healthfirst.org/health_info/your_health_first/kids/p
ain.cfm
Common Fallacies and Myths about
Pain in Children
Nursing Process Overview for the
Child in Pain
• Assessment
– Health history
• Questioning the child
• Questioning the parents
• Physical examination using pain rating scales
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Neonatal Infant Pain Scale
FLACC scale
FACES pain rating scale
Oucher pain rating scale
Poker chip tool
Word-graphic rating scale
Visual analog and numerical scales
Adolescent pediatric pain tool
Nursing Process Overview for the
Child in Pain
• Nursing diagnoses
• Patient-centered Goals
• Interventions to minimize
or relieve pain
• Evaluation – were goals
achieved? If not, modify plan
Pain Assessment
• Three types of measures to assess child’s pain:
– Behavioral
– Physiologic
– Self-report
In other words, note:
What the child says . . .
What the child is doing . . .
How the child’s body is reacting . . .
Pain in Neonates
• Difficult to assess
• Can only be based on physiologic and
behavioral responses
– Crying, grimacing, irritability, poor feeding or sleep
– Physiologic: increased heart rate, or bradycardia in newborns;
decreased O2 sat,vagal tone; palmar or plantar sweating
– Assessment tools
• CRIES
• PIPP (Premature Infant Pain Profile)
• NPASS (Neonatal Pain, Agitation, and Sedation
Scale)
Facial Expression of Pain
FIG. 7-1 Full, robust crying of preterm infant after
heel stick. (Courtesy Halbouty Premature Nursery,
Texas Children’s Hospital, Houston; photo by Paul
Vincent Kuntz.)
FIG. 7-2 The face of pain after heel stick. Note eye
squeeze, brow bulge, nasolabial furrow, and
widespread mouth. (Courtesy Halbouty Premature
Nursery, Texas Children’s Hospital, Houston; photo
by Paul Vincent Kuntz.)
Young Infant’s Response to Pain
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Generalized response of rigidity, thrashing
Loud crying
Facial expressions of pain (grimace)
No understanding of relationship between
stimuli and subsequent pain
• Look at
FLACC Scale
- Looks at behaviors of child
– Face
– Legs
– Activity
– Cry
– Consolability
• Assign a number 0 – 2 based on
observations
• Obtain rating of 0 – 10 (0=none; 10=worst)
• Read following slide on FLACC Scale
Assess these babies using the FLACC Scale
http://www.youtube.com/watch?v=_AUtYTaYMrE&feature=relateddren
http://www.youtube.com/watch?v=33xmiil0R8Y&feature=related
Older Infant’s Response to Pain
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Withdrawal from painful stimuli
Loud crying
Facial grimace
Physical resistance
Young Child’s Response to Pain
• Loud crying, screaming
• Verbalizations: “Ow,”
“Ouch,” “It hurts”
• Thrashing limbs
• Attempts to push away
stimulus
Body Outlines is a useful tool that allows children
to color the area that hurts. Coloring is a favorite
pastime for children. They tend to associate blue
with cold and red with hot. What color is pain?
School-Age Child’s Response to Pain
• Stalling behavior (“Wait a minute”)
• Muscle rigidity
• May use all behaviors of young child
Pain Rating Scales for Children
• FACES
• OUCHER
• Numeric scale
• Color tool
Adolescent
• Less vocal protest, less
motor activity
• Increased muscle tension
and body control
• More verbalizations (“It
hurts,” “You’re hurting me”)
Management of Pain
• Nonpharmacologic management
– Behavioral–cognitive strategies
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Relaxation
Distraction
Imagery
Biofeedback
Thought stopping
Positive self-talk
Pain, 2nd Edition - Clinical Manual
Margo McCaffery, RN, MS, FAAN; and Chris Pasero, RN, MSNc
Copyright 1999
• Another great resource to learn about Pain management
Pain Management
• Nonpharmacologic management
– Pain-controlling strategies: involve imagination,
play, diversion
– Virtual reality
– Containment and swaddling
– Proper positioning and tucking
– Sucking on pacifier, oral sucrose pre-procedure
– Kangaroo care: skin-to-skin with parent during
procedure, while in ICU
Management of Pain
• Nonpharmacologic management
– Biophysical interventions
• Heat and cold applications
• Massage and pressure
• Transcutaneous electrical nerve stimulation (TENS)
– Nurse’s role in non-pharmacologic pain
intervention
Management of Pain
• Pharmacologic management
– Medications used for pain management
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Nonopioid analgesics
Opioid analgesics
Adjuvant drugs
Anesthetics
World Health Organization (WHO) Pain
Ladder
• http://www.whocancerpain.wisc.edu/?q=node/130
• http://www.cfp.ca/content/56/6/514.full
Management of Pain
• Pharmacologic management
– Drug administration methods
• Oral method
• Rectal method
• Intravenous method
– Patient-controlled analgesia
• Epidural analgesia
• Conscious sedation
• Local anesthetic application
– Topical forms
– Injectable forms
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)
Children with Chronic Illness and Complex Pain
• Important components of assessment:
– A trusting relationship with child and family
– Onset of pain
– Pain duration or pattern
– Effectiveness of current treatment
– Factors aggravating or relieving pain
– Concurrent symptoms and complications
Pharmacologic management
• Nonopioids for mild to moderate pain
– Acetaminophen: Child dose 10-15
mg/kg/dose every 4-6 hours not to
exceed 5 doses/24 hours or 75mg/kg/day
– NSAIDS: ibuprofen – dose < 6 months 510mg/kg/dose q. 6-8 hours oral. MDD
40mg/kg/day
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- naproxen: dose > 2 years
10mg/kg/day oral divided into 2 doses
Opioids for Children
• Morphine
– Oral: 0.2-0.4mg/kg q 3-4 hours (short-acting)
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0.3-0.6mg/kg q 12 hours (long-acting)
– Parenteral: 0.1-0.2mg/kg IM q 3-4 hours
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0.02-0.1 mg/kg IV bolus q 2 hours
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0.015 mg/kg q 8 minutes by PCA
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Hydromorphone (Dilaudid)
Fentanyl: 5-15 mcg/kg. Max, dose= 400mcg.
Hydrocodone and acetaminophen (Vicodin)
Oxycodone/oxycontin (alone, also in Percocet)
Codeine
Methadone
Other Methods to Manage Pain
• Topical anesthetics
– EMLA (eutectic mixture of lidocaine and prilocaine) for pain from
skin puncture
• Apply 1 hour before and cover with dressing
– LMX (lidocaine) topical works in 30 minutes
• Vapocoolant: Pain Ease – sprayed on skin 10-15 seconds before
injection
• Rectal medications
• Regional nerve blocks
• Inhalation: nitrous oxide
• Epidural or Intrathecal: catheter into epidural, caudal or
intrathecal space to infuse opioids or anesthetic
Patient Controlled Analgesia (PCA)
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Following appropriate pre–operative teaching children as young as seven
years of age can learn to use a PCA pump.
– Occasionally there is a particularly bright 5 or 6 year old that also makes a good
candidate.
– Parent Controlled analgesia should be discouraged since it circumvents the internal
safeguard of PCA. Some centers, however, encourage a parent controlled analgesia in
children with chronic pain from Cancer or Acquired Immunodeficiency Syndrome.
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Parent Assisted Analgesia is a compromise where by both parent and child
decides on appropriatness of using the PCA Device.
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Typical MSO4 Dosing regimen: Increment 20–30 mcg/kg:
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– Morphine is the preferred immediate post-operative medication unless child has
allergy or unmanageable side effects
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Lockout 7 min
basal. 15 mcg/kg/hr.
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4hr limit 300 mcg/kg
Use of a background infusion is controversial. It might provide better anal
gesi
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http://www.spineuniverse.com/print/professional/treatment/non-surgical/acute-postoperative-pain-management-children
Managing Side Effects of Opioids
• Constipation: ALWAYS a side effect
– Laxatives: senna, lactulose, mineral oil, MOM
– Stool softeners: Colace
– Fluids, juices, excercise
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Sedation: caffeine; dextroamphetamines
Nausea and Vomiting: promethazine (Phenergan); ondansetron (Zofran)
Pruritis: diphenhydramine (Benadryl); hydroxyzine (Atarax)
Dysphoria, confusion, hallucinations: Haldol; adjust dose or stop
Urinary retention: oxybutynin; adjust dose or stop
Respiratory depression
– Mild to moderate: reduce dose by 25% or hold
– Severe: Naloxone (Narcan)
Adjuvant Drugs
• Antidepressants:
– amitriptyline, nortriptyline
– Neuropathic pain
• Anticonvulsants:
– gabapentin; carbamazepine
– Neuropathic and phantom limb pain
• Anxiolytics:
– Lorazepam (Ativan) anxiety
– Diazepam (Valium) muscle spasms
• Corticosterioids
– Dexamethasone
– Increased intracranial pressure, boney metastasis, spinal or nerve compression
• Others:
– Clonidine (anti-hypertensive)
– Neuropathic pain, phantom limb pain
Complementary pain medicine
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Biological: foods, special diets, herbals, vitamins
Manipulative treatments: chiropractic, massage
Energy based: Reiki, bioelectric or magnetic
Mind-Body techniques: mental or spiritual healing,
hypnosis, relaxation
• Alternative medical systems: homeopathy,
naturopathy, Chinese medicine like acupuncture
End of Presentation