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Identify pediatric patients at high risk for adverse opioid-related outcomes (e.g., pediatric patients with sleep apnea, receiving continuous IV opioids, or on supplemental oxygen).undefined#ref2">2
Effective pain management considers factors that influence pain assessment, such as the patient’s pain history, current pain, developmental level, coping strategies, and cultural background. For the pediatric patient in hospice or palliative care, the nurse should collaborate with the patient, family, and caregivers to set pain management goals, to identify methods and techniques that have been successful in the past, and to identify behaviors and cues that indicate the presence of pain.
Barriers to adequate treatment of pain in pediatric patients can be overcome when the hospice or palliative care team understands:
Pain is a complex phenomenon that is much more than a single sensation caused by a specific stimulus. The most effective pain management involves a combined approach of developmentally appropriate nonpharmacologic strategies along with the administration of medications. Nonpharmacologic strategies3 may include cold or warm packs; comfort measures such as talking or singing with the family, hugs, hand-holding, or a back massage, and distractions such as games, bubbles, videos, and listening to music or music therapy. Acupressure, acupuncture, aromatherapy, and massage have been effective in alleviating pain in pediatric patients near the end of life.5 There is a common value in hospice and palliative care that the pediatric patient should not live or die in pain, so that nonpharmacologic interventions should not replace pharmacologic interventions. These should be considered as concomitant strategies to control pain.
The World Health Organization (WHO) stepladder approach, adapted for pediatric patients, includes a two-step program for pain management. This approach is appropriate for pain in the terminally ill patient for most nociceptive, visceral, and somatic pain. The first step is the use of nonopioids, such as acetaminophen, for mild pain; the second step is the use of pure or strong opioids, such as morphine, fentanyl, or methadone, for moderate to severe pain. The use of weak opioids, such as codeine, hydrocodone, and tramadol, are contraindicated for use in the pediatric population because of potential risks and uncertainty of response in children. Opioid doses in pediatric patients should be titrated and based on patient-specific factors.4 Use extreme caution when calculating the dose for sublingual or buccal opioid administration. The small volume needed for absorption increases the risk of medication error. Adjuvant medications can be included at any time. Examples of adjuvant medications include clonidine (which can enhance the relief obtained by opioid medications), gabapentin, low-dose naloxone, baclofen, lorazepam, sucralfate, corticosteroids, and amitriptyline.1,5
Breakthrough pain can occur with suctioning, repositioning, or other activity. This can be avoided with premedication before engaging in activity that may exacerbate pain.
Some patients may be on a basal rate of analgesic medication or extended-release medication. A basal rate is a continuous low-dose analgesic to keep a steady state of pain relief without peaks and valleys. This is usually administered with patient-controlled analgesia (PCA). When pain becomes more than this basal rate or extended-release medication can manage, additional medication may be needed. The use of an extended-release opioid is generally administered two or three times per day.3 Breakthrough pain can occur with suctioning, repositioning, strong emotional responses, or physical activity. Breakthrough pain can be treated with an immediate-release opioid or activation of the PCA pump. It can also be avoided with premedication before engaging in activity that is expected to exacerbate pain. If breakthrough pain occurs repeatedly, the basal rate or extended-release analgesic medication should be adjusted to prevent a recurrence. The addition of low-dose naloxone to the basal rate of the opioid has been shown to reduce the incidence and severity of opioid-related constipation, pruritus, and nausea.1
Many families have concerns about addiction. Nurses must understand the differences between addiction, physical dependence, and tolerance. Addiction is the psychological craving for the medication or drug. This occurs rarely in young children, but it can be seen in adolescents. Dependence is when physical symptoms develop after a medication or drug is discontinued. Tolerance occurs when the body becomes accustomed to the medication or drug and a higher dose is required for the same level of pain relief.
As the patient nears the end of life, pain can become worse, tolerance to opioids escalates, and the oral route may not be available as the patient loses the ability to swallow. Opioid rotation can address some of these challenges. Opioid rotation includes changing to a different medication using the same route of administration, maintaining the current medication but changing the route of administration, or changing both the medication and the route of administration. Using an equianalgesic dose chart can help facilitate these changes.5 Alternative routes may also be used for opioid administration. These routes include sublingual or buccal, dermal, and intravascular.
Successful pain management requires a holistic approach to the broad spectrum of problems in pediatric patients who are at the end of life, their family, and caregivers.3 When providing pain management to these patients, the health care team needs to recognize the impact that unresolved psychosocial and spiritual issues can have on pain management. A multidisciplinary hospice team can provide support for terminally ill children and their families.
Consider the benefit of an intervention versus the burden to the patient. The goal of care is to reduce the patient’s anxiety and pain and increase the patient’s comfort and happiness at the end of life. Consider the impact to the family and caregivers.
Rationale: Turning and repositioning reduces pain stimulation and pressure receptors and maximizes the response to pain-relieving interventions.
Rationale: The family’s and caregivers’ presence and participation are key parts of the patient’s care.
Rationale: Premedication prevents or minimizes unpleasant responses to painful activities (e.g., suctioning, repositioning). When a painful reaction is common to the patient, the patient should not have to wait to ask for treatment.
Rationale: Reassessments identify the effectiveness of current pain management and guide further efforts of pain management.
Rationale: Making this record available to the patient, family, and caregivers helps them continue adequate pain management when the hospice or palliative care team is not present.
Rationale: Comparing the ability to function before and after pain-relieving interventions determines their effectiveness, especially in patients who are nonverbal.
Report to the practitioner an inability to function, perform ADLs, play, or interact.
Rationale: Side effects of analgesics may be controlled by reducing the dose, increasing time intervals between doses, or administering adjuvant analgesics.
Report to the practitioner excessive somnolence, respiratory depression, pruritus, nausea, and vomiting.
Report to the practitioner irritability, tremors, hyperactivity, seizures, insomnia, abdominal cramping, nausea, vomiting, diarrhea, sweating, fever, chills, nasal congestion, rhinitis, tachypnea, and tachycardia, all without other physiologic causes.
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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