Pain Assessment and Management (Pediatric) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Assess the patient’s pain status using a validated, developmentally appropriate pain scale.

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 patient’s pain history, current pain, developmental level, coping strategies, and cultural background. The patient’s responses to pain should be assessed at the patient’s cognitive and developmental levels.

Because each patient’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. A pain assessment should include self-report, behavioral observations, and physiological measures. 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 patient 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 patient’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.^{undefined#ref5">5}

Barriers to treating pain in pediatric patients include:⁵

• The myth that pediatric patients do not feel pain, that they feel pain less intensely than adults, or that because they do not remember painful events, pain management is less important than in adult patients
• Lack of knowledge of expected growth and development in pediatric patients
• Lack of understanding of how to apply pain management tools validated for pediatric patients
• Inability to recognize signs of pain in pediatric patients who are unable to communicate verbally
• Misinterpretation of pain cues in pediatric patients 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 using opioids to treat pain in children. 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.

Pediatric patients 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 patient’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 2) (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 physiologic and psychological patient outcomes. Developmentally appropriate pain scales include selected behavioral pain assessment scales for young children (Table 1), pain rating scales for children (Table 2), pain assessment scales for infants (Table 3), the Wong-Baker FACES^® Pain Rating Scale (Figure 1), and the Faces Pain Scale–Revised (FPS-R).⁶

Different scales are used because pediatric patients (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 (e.g., Wong-Baker FACES Pain Rating Scale) have been devised to allow children (approximately 3 years old and older) to depict the intensity of their pain more precisely.¹

The most commonly used scales for newborns include those related to behavior.⁵ The revised Face, Legs, Activity, Cry, Consolability (rFLACC) scale (Table 1) is a behavioral scale used to assess pain in infants and young or nonverbal patients.⁴ 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 and older), they can generally use the same scales as an adult (e.g., Visual Analog Scale [VAS] [Table 2], Numeric Scale [Table 2]) without difficulty.¹ Pain assessment tools that have been developed for the neurologically impaired child include the Non-Communicating Children’s Pain Checklist–Revised (NCCPC-R) and the Pediatric Pain Profile (PPP).¹

Critically ill children 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 patients. 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.

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

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

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

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s developmental level and ability to interact. Consider that a patient 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 patient’s and family’s experiences with pain.
6. Assess for factors that may alter the patient’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 patient for increased risk of pain (e.g., invasive procedure or intervention, anxiety, unable to communicate, or chronic illness).
8. Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of pain assessment and management.
9. Assess the patient’s and family’s ability to understand the selected pain assessment tool.
10. Consider the patient’s and family’s culture, including their beliefs and practices, in the pain assessment and plan accordingly.
11. Verify the patient’s opioid status (naive versus tolerant).³ 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 patient’s vital signs before pain assessment and management to compare them to vital signs after interventions to treat pain.

Preparation

1. Prepare the patient’s environment for a potentially painful procedure or treatment if applicable. If possible, provide an alternative space (often referred to as a treatment room) for a patient who is admitted to keep the patient’s bed and room as a safe place.
   1. Adjust the temperature, lighting, and sound to suit the patient 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 patient.
2. Explain the procedure or treatment steps to the family and patient (as developmentally appropriate) to minimize pain stimuli.
   1. Base the timing of explanations on the patient’s developmental stage.
      1. Explain painful stimuli to a young patient only immediately before the stimuli.
      2. Discuss the planned procedure with an older patient before the event.
   2. Consider medical play, if age appropriate, to assist the patient with coping with the procedure.
   3. Offer actual choices that fit the patient’s age and cognitive ability. Offer a young patient only one or two choices. For example, offer water or juice with the medication.

      Never ask if the patient 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 patient and family understand the purpose of a pain assessment tool and that questions are answered.
5. Obtain the patient’s weight in kilograms. Do not use stated, estimated, or historical weight.³
6. Verify the practitioner’s order.

PROCEDURE

1. Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Quietly observe the patient, 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 patient’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 patient’s pain when moving, lying down, and sitting. Monitor the patient 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 patient is physically and developmentally able to use the self-report scale.

10. Assess and assign a score for the patient during activities such as coughing and repositioning and compare those scores with scores obtained when the patient is quiet.

    Rationale: The patient’s pain rating and assessment may vary with activity and should guide pain management.

11. Ask if the patient is in pain and accept the patient’s subjective report of pain. If the patient is nonverbal or unable to give a subjective report of pain, engage the family in assessing the patient’s pain from nonverbal indicators.

    Rationale: Pediatric patients 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 patients, family involvement is essential.

12. Examine the site of the patient’s expressed pain or discomfort. Using age-appropriate words, inform the patient before the examination exactly what will happen. Encourage the family to assist in the assessment by distracting the patient with a toy, patting the patient’s head, and touching to console the patient.
    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 patient 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 patient, use words and phrases that the patient understands, such as “no hurt” or “biggest hurt.”
    2. Learn and use the individual patient’s words for pain.
       1. Ask the patient what makes the pain better or worse.
       2. Ask the patient what the pain feels like, or ask about the patient’s boo-boo. Use open-ended questions.
       3. Ask the patient to show where the pain is coming from on the body or on a stuffed animal.
       4. Ask the patient to rate the pain using a pain-intensity tool that is appropriate for the patient’s age, developmental level, and comprehension.

          Consistently use the same pain-intensity tool with the same patient.

          If the patient is unable to report the pain intensity, ask the patient 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 patient 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 patient and family how the pain affects activities of daily living (ADLs), play, school, and relationships.
14. Remove as many uncomfortable stimuli as possible.
15. Assist the patient 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.

16. Provide pharmacologic intervention as prescribed.
17. Provide appropriate psychosocial interventions to help the patient relax.
    1. Offer the patient a favorite security object (e.g., special blanket).
    2. Swaddle an infant to give a secure feeling.
    3. Alleviate anxiety by giving information.
    4. 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 patient as much as possible and appropriate.

    Rationale: The family’s presence is a key part of the patient’s care.

19. Compare the patient’s current pain intensity or score with the previously set goal at intervals per the organization’s policy or after a nonpharmacologic or pharmacologic intervention.
20. Discard supplies, remove PPE, and perform hand hygiene.
21. Document the procedure in the patient’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 patient.
   2. Reassess (or collaborate with the family or caregivers to reassess) pain on a scheduled basis for a patient 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 patient’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 patient’s ability to function, perform ADLs, play, and interact before and after pain interventions. Use some form of play with the patient 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 patient’s status regarding pain and pain-relieving interventions.
6. Begin interventions to prevent or treat constipation (e.g., stool softeners, fiber, bowel regimen) for patients receiving opioid medications.
7. Monitor a pediatric patient who has received opioids or benzodiazepines for a prolonged period as, without weaning, signs of withdrawal most often occur 24 to 72 hours after discontinuing the medication.² A patient who has been receiving continuous infusions of opioids and benzodiazepines is at greater risk.

   Rationale: The potential for withdrawal is most common 24 to 72 hours after discontinuation of opioids and benzodiadepines.²

   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

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

UNEXPECTED OUTCOMES

• Patient 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.
• Patient 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 patient.

DOCUMENTATION

• Date, time, location, type, and pain rating and the pain assessment tool used (e.g., FACES or rFLACC)
• Pain-relieving interventions given and their effectiveness (e.g., adequate or inadequate)
• Reductions in the patient’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 patient’s response to interventions
• Patient’s opioid status (naive versus tolerant)
• Individualized goals for weaning opioids and benzodiazepines (if applicable)
• Whether the patient is sedated or paralyzed and physiologic cues that helped determine that the patient was in pain (if applicable)
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Brand, K., Al-Rais, A. (2019). Pain assessment in children. Anaesthesia & Intensive Care Medicine, 20(6), 314-317. doi:10.1016/j.mpaic.2019.03.003
2. Hellsten, M. (2022). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 114-147). St. Louis: Elsevier.
3. Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved December 14, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
4. MacKeil-White, K. (2023). Chapter 3: Pediatric differences. In ENPC: Emergency nursing pediatric course: Provider manual (6th ed., pp. 29-46). Burlington, MA: Jones & Bartlett Learning. (Level VII)
5. 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. 1-34). New York: Springer Publishing Company. (Level VII)
6. 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.

ADDITIONAL READINGS

Laures, E.L. and others. (2021). Pediatric pain assessment in the intensive care unit: An evidence-based algorithm. Pain Management Nursing, 22(3), 260-267. doi:10.1016/j.pmn.2020.10.005

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: February 2024