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Jan.30.2020

Pain Assessment and Management (Pediatric) - CE

ALERT

Use a developmentally appropriate, validated pain scale to assess a child’s pain.

Identify children at high risk for adverse opioid-related outcomes (e.g., patients with sleep apnea, receiving continuous IV opioids, or on supplemental oxygen).undefined#ref1">1

OVERVIEW

Pain is a complex phenomenon that is much more than a single sensation caused by a specific stimulus. Factors that influence pain assessment include the child’s pain history, current pain, developmental level, coping strategies, and cultural background. The child’s responses to pain should be assessed at his or her cognitive and developmental level.

Because each child’s experience is personal, pain management requires an individualized approach. The most effective pain management involves a combined approach of developmentally appropriate nonpharmacologic strategies with the administration of pharmacologic agents.

Through a comprehensive pain assessment, the nurse can begin to understand the impact of pain. The nurse should explain to the family that the nature of pain is subjective and individual. Pain assessment requires that the nurse work with the child and family to identify the level of pain before management of pain is considered.

Pain is easier to prevent than to treat. For procedural pain, a topical analgesic cream applied to the skin can prevent or limit the pain and manage the child’s fear and anxiety. For postoperative, acute, or chronic pain, administering pharmacologic agents at regular intervals (around-the-clock) rather than on an as-needed basis is preferable to prevent pain.3

Barriers to treating pain in pediatric patients include:3

  • The myth that infants and children do not feel pain, that they feel pain less intensely than adults, or that because they don’t remember painful events, pain management is less important than in adult patients.
  • Lack of knowledge of expected growth and development in children
  • Lack of understanding of how to apply pain management tools validated for infants and children
  • Inability to recognize signs of pain in children who are unable to communicate verbally
  • Misinterpretation of clues to pain in children as the absence of pain (e.g., playing to distract themselves from pain, sleeping to try to ignore pain)
  • The fear of respiratory depression or other adverse reactions from analgesic medications

An understanding of tolerance, dependence, and addiction is vital when treating pain for children with opioids. When assessing the presence and level of pain, tolerance is the most important factor. Tolerance is the body’s response to repeated administration of opioids, where the body becomes accustomed to the dose received and requires higher dosing to achieve the same relief. The nurse cannot assume adequate pain relief with the same dose and frequency of opioid medication.

Infants and children who are critically ill and receiving neuromuscular blockade are not able to express pain by means of facial expression, crying, clenched muscles, or restlessness. An increased heart rate and respiratory rate may be the only indicators of pain for these children. Nurses must be aware of activities or situations that may cause pain and look for these subtle signs.

A pain assessment is not equivalent to a sedation assessment. Both pain and sedation assessments are necessary, and when accomplished together, both guide optimal management to prevent physiologic pain and anxiety, inefficient ventilation, hypoxia, agitation, self-harm, and awareness of a potentially frightening environment.

Infants and children may respond to pain differently than an adult because of their varied developmental levels. For example, they may cry and thrash about, have sleep disturbances, have a shortened attention span, suck, rock, refuse to eat or play, become quiet and withdrawn, or become active. Therefore, understanding the child’s growth and development should be the nurse’s initial step in making a comprehensive pain assessment using a developmentally appropriate pain assessment tool (Table 1)Table 1 (Table 2)Table 2 (Table 3)Table 3.2

The purpose of pain assessment scales is to consistently use a valid, reliable measurement scale to guide clinical pain management toward meeting desired physiological and psychological patient outcomes. Developmentally appropriate pain scales include selected behavioral pain assessment scales for young children (Table 1)Table 1, pain rating scales for children (Table 2)Table 2, pain assessment scales for infants (Table 3)Table 3, the Wong-Baker FACES® Pain Rating Scale (Figure 1)Figure 1, and the Faces Pain Scale–Revised (FPS-R).4

Different scales are used because children (especially young children) have a limited range of experience and may be unable to use appropriate words to express their discomfort adequately. Observational pain scales are appropriate for neonates and infants to allow pain assessment in those unable to verbalize pain. Simple self-report scales using facial expressions (i.e., Wong-Baker FACES Pain Rating Scale) have been devised to allow preschool and school-age children (about 8 years old and older) to depict the intensity of their pain more precisely.

The most commonly used scales for newborns include those related to behavior.5 The Face, Legs, Activity, Cry, Consolability (FLACC) scale (Table 1)Table 1 is a behavioral scale that is used to assess pain in infants and young or nonverbal children.5 Beginning during the toddler years, children have acquired words for pain, and preschool-age children may be able to report pain, indicate its location, and describe its characteristics. If self-report is possible, this method is preferred.5 As school-age children learn the proportionality of numbers and colors (typically at 8 years of age and older), they can generally use the same scales as an adult (e.g., Visual Analog Scale [VAS] [Table 2Table 2], Numeric Scale [Table 2Table 2]) without difficulty.5

Collaborating with the family members will give insight into their perception of the child’s behavior and expressions of pain. Communication with the child, family, and other health care personnel is essential for a comprehensive assessment, which allows for provision of the best possible pain relief for the child.

CHILD AND FAMILY EDUCATION

  • Provide individualized, developmentally appropriate education to the family and child based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Collaborate with the child and family to develop a pain management plan and review relevant age-specific pharmacologic and developmentally appropriate nonpharmacologic pain-relieving interventions.
  • Collaborate with the child and family to set a goal for pain management.
  • Identify nonpharmacologic pain treatment modalities that were successful for the child’s previous experiences with pain.
  • Explain that consistent and accurate assessments of pain are necessary to treat the child’s pain appropriately.
  • Provide information about the physiological and psychological effects of undertreated pain.
  • Collaborate with the family to learn and identify the child’s pain cues and behaviors.
  • Select and explain how an appropriate pain scale is used.
  • Explain to the family the importance of their involvement in rating the child’s pain, particularly with infants and younger children.
  • Explain to the family that a child experiencing pain may regress to an earlier developmental level.
  • Screen for history of opioid dependence.
  • Discuss opioids with the child and family; explain their use in pain management and allay any fears of addiction. Explain the effects of tolerance, dependence and addiction.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Child and Family Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the child and family.
  3. Verify the correct child using two identifiers.
  4. Assess the child’s developmental level and his or her ability to interact. Consider that a child who does not understand the concept of numeric ordering (e.g., 5 is more than 3) is unable to use self-report numeric scores correctly.
  5. Assess the child’s and family’s experiences with pain.
  6. Assess for factors that may alter the child’s ability to express pain (e.g., inability to communicate, immobilization, neuromuscular blockade, neurologic deficit, and medications affecting heart rate and blood pressure).
  7. Assess the child for increased risk of pain (e.g., invasive procedure or intervention, anxiety, unable to communicate, or chronic illness).
  8. Assess the child’s and family’s understanding of the reasons for and the risks and benefits of pain assessment and management.
  9. Assess the child’s and family’s ability to understand the selected pain assessment tool.
  10. Consider the child’s and family’s culture, including their beliefs and practices, in the pain assessment and plan accordingly.
  11. Assess for concomitant symptoms from side effects of opioids, such as constipation, nausea, vomiting, pruritus, sedation, respiratory depression, confusion, hallucinations, and urinary retention.2
  12. Assess and document the child’s vital signs before pain assessment and management to compare them to vital signs after interventions to treat pain.

Preparation

  1. Prepare the child’s environment for a potentially painful procedure or treatment. If possible, provide an alternative space (often referred to as a treatment room) for a child who is admitted to keep his or her bed and room as a safe place.
    1. Adjust the temperature, lighting, and sound to suit the child and family without interfering with the ability to perform the procedure.
    2. Minimize activity by preventing unnecessary interruptions, coordinating activities, and planning for rest periods. Consider clustering care around pain medication administration times.
    3. Provide privacy for the child.
  2. Explain the procedure or treatment steps to the family and child (as developmentally appropriate) to minimize pain stimuli.
    1. Base the timing of explanations on the child’s developmental stage.
      1. Explain painful stimuli to a young child only immediately before the stimuli.
      2. Discuss the planned procedure with an older child before the event.
    2. Consider medical play, if age appropriate, to assist the child with coping with the procedure.
    3. Offer actual choices that fit the child’s age and cognitive ability. Offer a young child only one or two choices. For example, offer water or juice with his or her medication.
      Never ask the child if he or she does or does not want to take medication.
    4. Consult with a child life specialist, if available and necessary.
  3. Select and obtain a developmentally appropriate and organization-approved pain scale.
  4. Ensure that the child and family understand the purpose of a pain assessment tool and that questions are answered.
  5. Obtain the child’s weight in kilograms.
  6. Verify the practitioner’s order.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct child using two identifiers.
  3. Explain the procedure to the child and family and ensure that they agree to treatment.
  4. Quietly observe the child, noting any signs of agitation or guarding of a pain site.
    Consider multiple causes for agitation, including hypoxia, emotional distress, environmental factors, medication reactions, or pain. Ensure that the cause is treated.
  5. Assess for physiologic indicators of pain, such as heart rate, blood pressure, and respiratory rate and effort, before beginning any painful procedure. Compare these vital signs to the ones obtained after the procedure began.
    Rationale: Physiologic indicators are nonspecific, but they may be indicative of pain and are altered by stimulation.
  6. Ask the family what they believe is the child’s level of pain or discomfort. Agitation may be interpreted as pain.
    Rationale: Family members know their child best and may be able to interpret behavior cues that are indicative of pain.
  7. Assess the child’s pain when he or she is moving, lying down, and sitting. Monitor the child for guarding of potentially painful areas with changes in position.
  8. If using an observational scale, use the scale as directed and determine a pain score.
  9. If using a self-report scale, use the scale as directed and determine the pain score.
    For reliability, ensure that the child is physically and developmentally able to use the self-report scale.
  10. Assess and assign a score for the child during activities such as coughing and repositioning and compare those scores with scores obtained when the child is quiet.
    Rationale: The child’s pain rating and assessment may vary with activity and should guide pain management.
  11. Ask the child if he or she is in pain and accept his or her subjective report of pain. If the child is nonverbal or unable to give a subjective report of pain, engage the family in assessing the child’s pain from his or her nonverbal indicators.
    Rationale: Children may be reluctant to report pain because they may have misconceptions about the cause of their pain or they may fear the consequences, such as another painful procedure or an injection. For most children, family involvement is essential.
  12. Examine the site of the child’s expressed pain or discomfort. Using age-appropriate words, inform the child before the examination exactly what will happen. Encourage the family to assist in the assessment by distracting the child with a toy, patting the child’s head, and touching to console him or her.
    1. Include inspection (discoloration, swelling, drainage), palpation (change in temperature, area of altered sensation, painful area, areas that trigger pain, areas that reduce pain), and range of motion in the involved joints (if applicable).
    2. Include auscultation to help identify abnormalities and determine the cause of pain.
    3. Familiarize the child and family with the assessment tool and equipment by using play as appropriate.
    4. Include a child life specialist in the assessment, if possible.
  13. Assess the characteristics of the pain.
    1. Use developmentally appropriate vocabulary. For a young child, use words and phrases that he or she understands, such as “no hurt” or “biggest hurt.”
    2. Learn and use the individual child’s words for pain.
      1. Ask the child what makes the pain better or worse.
      2. Ask the child what the pain feels like, or ask about his or her boo-boo. Use open-ended questions.
      3. Ask the child to show where the pain is coming from on his or her body or on a stuffed animal.
      4. Ask the child to rate his or her pain using a pain-intensity tool that is appropriate for the child’s age, developmental level, and comprehension.
        Consistently use the same pain-intensity tool with the same child.
        If the child is unable to report the pain intensity, ask him or her or the family if the pain is a lot, a little, or in between to provide an idea of the level of pain intensity.
      5. Ask the child if the pain is constant, intermittent, continuous, or a combination. Ask whether the pain increases during specific times of the day, with particular activities, or in specific locations.
      6. Ask the child and family how the pain affects activities of daily living (ADLs), play, school, and relationships.
  14. Perform hand hygiene and don gloves, if indicated.
  15. Remove as many uncomfortable stimuli as possible.
  16. Assist the child to a comfortable position within normal body alignment.
    Rationale: Turning and repositioning reduces pain stimulation and pressure receptors and maximizes the response to pain-relieving interventions.
  17. Provide appropriate psychosocial interventions to help the child relax.
    1. Offer the child a favorite security object (e.g., special blanket).
    2. Reduce environmental stimuli.
    3. Swaddle an infant to give him or her a secure feeling.
    4. Alleviate anxiety by giving information.
    5. Pray with the child and family, if appropriate.
    6. Provide sensory distraction, such as guided imagery, blowing bubbles, listening to music or music therapy, or playing a favorite video or video game.
  18. Encourage the family to participate and remain with the child as much as possible and appropriate.
    Rationale: The family’s presence is a key part of the child’s care.
  19. Compare the child’s current pain intensity with the previously set goal.
  20. Remove gloves, if worn, and perform hand hygiene.
  21. Document the procedure in the child’s record.

MONITORING AND CARE

  1. Assess, treat, and reassess pain.
    1. Use methods of pain assessment and specific behavioral indicators that are appropriate for the individual child.
    2. Reassess (or collaborate with the family or caregivers to reassess) pain on a scheduled basis for a child who reported pain on a previous assessment. Incorporate the assessment intervals into the treatment plan based on the organization’s practice for routine reassessments and on the child’s condition, including the cause of the pain, pain severity, and comorbidities.
    3. Adjust the intervals so that pain is reassessed for specific circumstances:
      1. With the occurrence of new pain or an exacerbation of previously reported pain
      2. With any activity or procedure that may cause or exacerbate pain
      3. After medication administration, per the medication’s expected onset of action
      4. Before and after a unit transfer
      5. At the time of a change in caregivers
  2. Monitor cardiopulmonary status and oxygen saturation.
    Reportable conditions: Hypoxia, hypotension, tachycardia, elevated blood pressure (may be indicators of inadequately treated pain)
  3. Compare the child’s ability to function, perform ADLs, play, and interact before and after pain interventions. Use some form of play with the child in the assessment(s), intervention(s), and evaluation(s).
  4. Evaluate for the presence of analgesic, sedative, or adjuvant medication side effects.
    Rationale: Side effects of analgesics may be controlled by reducing the dose, increasing time intervals between doses, infusing a small continuous dose of naloxone, or administering adjuvant analgesics.
    Reportable conditions: Excessive somnolence, respiratory depression, pruritus, nausea, vomiting
  5. Evaluate and assist the family’s coping with the child’s status regarding pain and pain-relieving interventions.
  6. Begin interventions to prevent or treat constipation (e.g., stool softeners, fiber, bowel regimen) for children receiving opioid medications.
  7. Monitor an infant or child who has received opioids or benzodiazepines for 5 or more days for withdrawal behaviors.1 A child who has been receiving continuous infusions of opioids and benzodiazepines is at greater risk.
    Rationale: The potential for withdrawal exists after 5 days of regular opioid or benzodiazepine administration. 1
    Reportable conditions: Irritability, tremors, hyperactivity, seizures, insomnia, abdominal cramping, nausea, vomiting, diarrhea, sweating, fever, chills, nasal congestion, rhinitis, tachypnea, tachycardia, all without other physiologic causes

EXPECTED OUTCOMES

  • Child verbalizes or exhibits nonverbal expressions of relief from pain.
  • Child’s function improves as evidenced by more restful sleep, improved nutrition, increased developmentally appropriate activity, and interactions with others.
  • Child is free from side effects of analgesic, sedative, or adjuvant medications.
  • Cardiopulmonary and oxygen saturation monitoring reflects pain relief.

UNEXPECTED OUTCOMES

  • Child or family verbalizes continued pain that exceeds pain-intensity goal, describes worsening of pain, displays nonverbal behavior reflecting pain (i.e., regresses further), or identifies pain in a different location.
  • Child experiences adverse reaction to medication or other interventions, such as apnea or bradypnea, nausea, vomiting, constipation, itching, sleepiness, or withdrawal.
  • Cardiopulmonary and oxygen saturation monitoring values are out of normal range for the child.

DOCUMENTATION

  • Date, time, location, type, and pain rating and the pain assessment tool used (e.g., FACES or FLACC)
  • Pain-relieving interventions given and their effectiveness (e.g., adequate or inadequate)
  • Reductions in the child’s function if observed, adverse reactions from pain interventions (pharmacologic and nonpharmacologic), or both
  • Findings of ongoing assessments, interventions completed (including notification of practitioner, if done), and child’s response to interventions
  • Individualized goals for weaning opioids and benzodiazepines (if applicable)
  • Expected and unexpected outcomes
  • Whether the child is sedated or paralyzed and physiologic cues that helped determine that the child was in pain (if applicable)
  • Unexpected outcomes and related nursing interventions
  • Child and family education

REFERENCES

  1. Joint Commission, The. (TJC). (2017). R3 report: Requirement, rationale, reference. Retrieved November 6, 2019, from https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf (Level D)
  2. Martin, S.D. and others. (2019). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s nursing care of infants and children (11th ed., pp. 137-167). St. Louis: Elsevier.
  3. Mullen, J.E., Pate, M.F.D. (2019). Chapter 1: Caring for critically ill children and their families. In M.C. Slota (Ed.), AACN core curriculum for pediatric high acuity, progressive, and critical care nursing (3rd ed., pp. 1-33). New York: Springer Publishing.
  4. Pasek, T.A. and others. (2015). The headache electronic diary for children with concussion. Clinical Nurse Specialist®, 29(2), 80-88. doi:10.1097/NUR.0000000000000108 (Level C)
  5. Zeltzer, L.K., Krane, E.J., Levy, R.L. (2020). Chapter 76: Pediatric pain management. In R.M. Kliegman and others (Eds.), Nelson textbook of pediatrics (21st ed., pp. 469-490). Philadelphia: Elsevier.

AACN Levels of Evidence

  • Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
  • Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
  • Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
  • Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
  • Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
  • Level M - Manufacturer's recommendations only
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