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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
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
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 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 physiological 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).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) 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 2], Numeric Scale [Table 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.
Never ask the child if he or she does or does not want to take medication.
Consider multiple causes for agitation, including hypoxia, emotional distress, environmental factors, medication reactions, or pain. Ensure that the cause is treated.
Rationale: Physiologic indicators are nonspecific, but they may be indicative of pain and are altered by stimulation.
Rationale: Family members know their child best and may be able to interpret behavior cues that are indicative of pain.
For reliability, ensure that the child is physically and developmentally able to use the self-report scale.
Rationale: The child’s pain rating and assessment may vary with activity and should guide pain management.
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.
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.
Rationale: Turning and repositioning reduces pain stimulation and pressure receptors and maximizes the response to pain-relieving interventions.
Rationale: The family’s presence is a key part of the child’s care.
Reportable conditions: Hypoxia, hypotension, tachycardia, elevated blood pressure (may be indicators of inadequately treated pain)
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
Rationale: The potential for withdrawal exists after 5 days of regular opioid or benzodiazepine administration.
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
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