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Home > Library > MANAGING THE PAIN: Assessing and managing pain in the pediatric patient |
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PAIN IS A SUBJECTIVE experience; for infants and children, it's possibly the most bewildering and frightening occurrence in their young lives. Until age 3 or so, children can't grasp abstract concepts, such as time, cause and effect, and quantification. Consequently, it's impossible for them to understand why pain occurs, or that relief is just around the corner. They know only that something hurts right now. What makes the experience particularly distressing is that infants and young children lack the language skills needed to tell someone they're in pain, where and how much it hurts, or to ask for help. Infants and children are uniquely dependent on the ability of their parents and healthcare providers to recognize the physiologic and behavioral signs of pain and to react by relieving their pain. Children expect these same caregivers to anticipate and prevent or minimize painful experiences whenever possible. Where does it hurt?
Assessing pain in infants and young children requires the cooperation of parents and the use of age-specific assessment tools. If the child can communicate verbally, he can also help the process. Normal clinical assessment involves a health history that includes a description of any pain and palliative measures along with a comprehensive physical exam. When assessing infants and children, you'll rely on parents for the health history and background on experience with pain. To help you better understand the child's pain, ask the parents these questions: * What kinds of pain has your child had in the past?
* How does your child usually respond to pain?
* How do you know your child is in pain?
* What do you do when he's hurting?
* What works best to relieve your child's pain?
* Is there anything special you'd like me to know about your child and pain?
The child's vital signs can be pain indicators. Elevated pulse, BP, or respirations can be signs of pain and stress. However, findings here must be viewed in conjunction with other assessment data because nonpainful stimuli can elicit changes in vital signs as well. For example, just touching an infant can speed or calm the child's pulse rate. Tools you can use
A number of proven assessment tools have been designed for young patients that seek to quantify the child's pain, one of the harder things to accomplish during assessment and observation. Using an assessment tool will help, but quantifying pain in the infant or preverbal child will still be difficult. Pain assessment tools are unidimensional (measuring or assessing one indicator) or multidimensional (measuring or assessing multiple indicators). Composite measures of pain include physiologic, behavioral, sensory, and cognitive indicators. These tools tend to be especially useful when assessing children under age 3 or older children with cognitive deficits. Because of the complexity of assessing pain in infants, there's no single pain measurement tool that works well for all patients. However, three multidimensional tools for measuring pain in infants have proved to be quite effective: the CRIES neonatal postoperative pain measurement scale, the neonatal infant pain scale, and the premature infant pain scale (see Measuring pain in infants). The CRIES inventory is one of the easier tools to use. Five separate factors are scored on a scale of 0 to 2. Infants with a score of 0 would be pain free. A total score of 10 would indicate extreme pain. Several simple and effective pain-measuring scales can help the child who is able to speak, usually by age 3, identify a level of pain. These include the faces pain scale (see The faces pain scale), a visual analog scale, and the chip pain-measuring tool.
A visual analog pain scale is simply a straight line with the phrase “no pain” at one end and the phrase “the most pain possible” at the other. Children who understand the concept of a continuum can mark the spot on the line that corresponds to the level of pain they feel. The chip tool uses four identical chips to signify levels of pain and can be used for the child who understands the basic concept of adding one thing to another to get more. If available, you can use poker chips. If not, simply cut four uniform circles from a sheet of paper. Here's how to present the chips: * First say, “I want to talk with you about the hurt you might be having right now.”
* Next, align the chips horizontally on the bedside table, a clipboard, or other firm surface where the child can easily see and reach them.
* Point to the chip at the child's far left and say, “This chip is just a little bit of hurt.”
* Point to the second chip and say, “This next chip is a little more hurt.”
* Point to the third chip and say, “This next chip is a lot of hurt.”
* Point to the last chip and say, “This last chip is the most hurt you can have.”
* Ask the child, “How many pieces of hurt do you have right now?” (You won't need to offer the option of “no hurt at all” because the child will tell you if he doesn't hurt.)
* Record the number of chips. If the child's answer isn't clear, talk to him about his answer, then record your findings.
Facing the pain
Behavior is the language infants and children rely on to convey information about their pain. Areas of behavior that change because of pain include body positioning, facial expression, patterns of eating and sleeping, attention level, and vocalization. In an infant, facial expression is the most common and consistent behavioral response to all stimuli, painful or pleasurable, and may be the single best indicator of pain for the healthcare provider and the parent. Facial expressions that tend to indicate that the infant is in pain include mouth stretched open, eyes tightly shut, brows and forehead knitted (as if they're in a grimace), and cheeks raised high enough to form a wrinkle on the nose. In young children, look for such signs as: * narrowing of the eyes
* grimace or fearful appearance
* frequent and longer lasting bouts of crying, with a tone that's higher and louder than normal
* less receptiveness to comforting by parents or other caregivers
* holding or protecting the painful area.
Enlist the parents' help in interpreting the child's crying. Pain may be the cause, but hunger, anger, fear, or a wet diaper can also elicit crying. Typically, parents can distinguish among the different cries of their child and help narrow down the possible causes. Crying associated with pain is distinguished by frequency, duration, pitch, and intensity. Cries of pain are usually short, sharp, higher in pitch, tense, harsh, nonmelodious, and loud. On the other hand, some infants don't cry in response to pain, even pain associated with an invasive procedure. Also, some treatments make crying impossible. Intubated infants, for example, can't produce an audible cry because the endotracheal tube passes through their vocal cords. However, these infants still exhibit the facial expressions that accompany crying —mouth opened wide and eyes tightly closed, insinuating crying. It's a mistake to rely too heavily on observed behavior alone when assessing pain in young patients. Some children will suffer pain rather than report it or allow others to see that they're in pain. Others are adept at distracting themselves and may appear pain free. Some children will sleep soundly, not because they have no pain, but because they're physically and emotionally exhausted. A child who is able to speak well can provide some useful information. However, keep in mind that his language skills are very basic and he may not understand words you use; you may call it pain, but he may think of it as a hurt or boo-boo. Find the words that work best by talking with his parents and with the child himself. Remember that children who are just learning to talk have a great deal more skill in reading the facial expressions and body language of their parents and caregivers. After all, they've been reading this language since birth. Be sure your expression and body posture are conveying a message consistent with your words. If you or his parents appear concerned, he may feel there's something to fear, and this may color his description of the pain he's feeling. Make it go away
Regardless of the underlying cause, pain management for infants and young children seeks to: * identify and relieve existing pain
* anticipate and prevent or minimize pain related to hospitalization, procedures, and treatments
* optimize pharmacologic and nonpharmacologic interventions to reduce stress, increase comfort, and enhance healing.
Pharmacologic therapy is the mainstay of pain management for an infant or a child. Selection of the medications, dosages, and administration routes depends on the specific needs of the patient. Opioid analgesics are highly effective pain relievers and constitute the core of most pharmacologic interventions to manage acute pain (especially postoperative pain) in infants and children. Morphine (MS Contin) and fentanyl (Duragesic) are the two opioids used most commonly in these patients. Morphine may provide better sedation and a lower risk of chest wall rigidity than fentanyl. Patient-controlled analgesia (PCA) can be useful in managing pain in the young patient, provided the parents are involved and they're trained in the theory and proper use of the equipment. PCA allows the patient to maintain a therapeutic level of the prescribed opioid analgesic at all times. It has proven effective in children ages 5 and older. Nonopioid analgesics, which include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), can help manage mild-to-moderate pain. In instances of severe pain, nonopioid analgesics in conjunction with opioid analgesics can reduce the required dosage of the opioid drug. Acetaminophen is the drug of choice for treating mild pain. It has the added benefit of helping reduce fever and is very safe, even for neonates. Acetaminophen has few adverse reactions or contraindications. However, long-term use can increase the risk of liver damage, and it's possible to reach a point at which additional doses no longer provide an analgesic effect. On the positive side, acetaminophen is available in suppository, liquid, and tablet form, making it easy to administer and appropriate for most situations. NSAIDs relieve mild-to-moderate pain and act as anti-inflammatory agents. Commonly prescribed NSAIDs, such as ibuprofen (Advil), naproxen (Naprosyn), indomethacin (Indocin), and ketorolac (Toradol), are approved for use in children. Possible adverse reactions of NSAIDs include inhibition of platelet aggregation and gastrointestinal irritation. Although there are no studies of the effectiveness of adjuvant therapy in infants and children, healthcare providers prescribe a wide range of medications as adjuvant therapy, usually when treating cancer pain in infants and children. Positive results have made adjuvant therapy more acceptable as a constructive facet of pain management in other chronic conditions as well, such as neuropathies and headache. Types of drugs used for adjuvant therapy and their therapeutic effects include: * antianxiety medications, such as lorazepam (Ativan), diazepam (Valium), and midazolam (Versed), which are used to enhance the effect of opioids
* anticonvulsants, such as phenytoin (Dilantin), carbamazepine (Tegretol), and gabapentin (Neurontin), which are used to treat neuropathies caused by certain diseases or trauma
* corticosteroids, which help alleviate severe inflammation and bone pain
* neuroleptic drugs, which are antipsychotic, tranquilizing, sedative, and analgesic, and help relieve pain associated with cancer, certain neuralgias, phantom limb, and muscular discomfort
* tricyclic antidepressants, such as amitriptyline (Elavil), which are sometimes used to manage headache and chronic pain
* topical or local anesthetics, which are given before procedures, such as I.V. insertion, to reduce procedural pain.
For the infant and young child, nonpharmacologic interventions pick up where drug therapies stop by reducing stress and anxiety and increasing comfort and security. These measures are just as critical to the patient's well-being as pain relief. Nonpharmacologic interventions cause no adverse reactions, require no special equipment, and can be used at any time. Cognitive-behavioral interventions for the infant include positioning, containment or swaddling, distraction, touching, and gentle massage. Placing an infant in a midline or supine position has a calming effect, as does wrapping him snugly in a soft blanket. Providing distraction —for example, with a bedside mobile or a safe, colorful toy or stuffed animal —helps the infant focus on something enjoyable rather than his pain. For a toddler, distraction, hypnosis, guided imagery, gentle massage, snuggling with mom and dad, and curling up in bed listening to a story are all methods of moving the child's focus away from his pain toward more serene, safe, and comforting thoughts. Thermotherapy is the most common form of physical therapy used with infants. Applying warm and cold to painful areas can make them feel better. Heat promotes circulation, and cold helps reduce swelling and provides a limited amount of numbing. Complementary therapies, such as music or aromatherapy, are gaining acceptance because of the influence music and aromas can have on emotions and state of mind. For the infant or child, soothing music has a calming effect and can help him drift off to sleep. More lively music can stimulate memories or encourage singing, which distracts the child for a while. Smells that remind him of mom, dad, or grandma's house can be comforting as well. Selected references
American Academy of Pediatrics/American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–797. Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manage Nurs. 2006;7(2):44–52. Lawes RN, Green L, Rogers M. Big meds for little bodies. Nursing Made Incredibly Easy! 2008:6(6):43–47. Nursing2009 Drug Handbook. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. Pediatric Nursing Made Incredibly Easy! Philadelphia, PA: Lippincott Williams & Wilkins; 2005:31–39. Saroyan JM, Schechter WS. Pediatric pain assessment. http://www.nhpco.org/i4a/pages/Index.cfm?pageID=4669 . Accessed November 5, 2008. |
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