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pain assessment.ppt
- 2. Pain Assessment in Children “Pain is whatever the patient says it is.”
- 3. Definition of pain • “Pain is whatever the experiencing person says it is, existing wherever and whenever he or she says it does.” (McCaffery) • Chronic Pain: Pain that has outlived it’s usefulness • Acute Pain: An adaptive, beneficial response necessary for the preservation of tissue integrity
- 4. Goals of Pain Assessment “Provide accurate information to determine which actions could be taken to alleviate the pain, and, on an ongoing basis evaluate the effectiveness of these actions.”
- 5. Myths About Pain Myths About Pain Neonates do not experience pain Children have no memory of pain There is a correct amount of pain for a given injury Children can easily become addicted to narcotics Narcotics can easily cause respiratory depression
- 6. Facts About Children & Pain Infants do feel pain Children do not tolerate pain better than adults Children can tell you where they hurt Children do not always tell the truth about pain
- 7. Facts About Children & Pain Children do not become accustomed to pain or painful procedures Behavioral manifestations of pain may not reflect pain intensity Narcotics are no more dangerous for children than adults
- 8. Children Do Not Tolerate Pain Better Than Adults • Children’s tolerance to pain actually INCREASES with age.
- 9. Children Can Tell You Where They Hurt • Children beyond infancy can accurately point to the body area or mark the painful site on a drawing; children as young as three years can use pain scales.
- 10. Children Do Not Always Tell The Truth About Pain • Children may not admit having pain to avoid an injection, because of constant pain, or because they believe others know how they are feeling.
- 11. Children Do Not Become Accustomed To Pain or Painful Procedures • Children often demonstrate INCREASED behavioral signs of discomfort with repeated painful procedures.
- 12. Behavioral Manifestations of Pain May Not Reflect Pain Intensity Children’s developmental level, coping abilities, and temperament, such as activity level and intensity of reaction to pain, influence pain behavior.
- 13. QUESTT….. • Question the patient • Use pain rating scale • Evaluate behavior and physiologic signs • Secure family’s involvement • Take cause of pain into account • Take action and assess effectiveness Multidimensional Model of Pain Assessment
- 14. Multidimensional Model of Pain Assessment (QUESTT) T
- 15. Question the Child Verbal Indications of Pain • Much less common than in adults • May not understand term, such as “pain” • May speak globally, such as “I don’t feel good” • May deny pain for fear of injection • Cries, screams, groans, moans
- 16. • Use a variety of words to describe pain, such as owie, boo-boo, ouch, hurt, • Know words in other languages Question the Child, cont.
- 17. Have Child Locate Pain by: • Marking body parts on a human figure drawing • Point to area with one finger on self, doll, stuffed animal • Point to “where mommy or daddy would put a bandage”
- 18. Use diagram to have child locate pain
- 20. Use Pain Rating Scale • In 2001 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) published Pain Standards • One of the standards is to make pain rating the 5th vital sign.
- 21. Use Pain Rating Scale, cont. • Select a scale that is suitable for the child’s age, abilities, and preferences • Teach child to use scale before pain is expected, such as preoperatively • Use same scale with child each time pain is assessed • Ask child about acceptable or functional pain level
- 22. Pain Assessment • Location • Characteristics • Onset / Duration • Frequency • Quality • Intensity / Severity • Precipitating Factors
- 25. Assessment Tools • Self-Report “The Gold Standard” • Observational Scales • Physiologic Parameters • Parent Report • Nurse Report
- 26. Self-Report • Description of Pain - type of pain - intensity of pain • Pain Scale Ratings
- 27. Observations • Vocalization / verbalization • Facial Expression • Body Language • Emotional State
- 28. Physiologic Parameters • Heart rate • Respiratory rate • Blood pressure • HR, RR, BP • shallow respirations • vagal nerve tone (shrill cry) • pallor or flushing • diaphoresis, palmar sweating • O2 saturation • EEG changes
- 29. Parent Vs. Nurse Report • Varying results in studies comparing parent, nurse, and self-report • May be especially useful in cognitively impaired children
- 30. Special Situations • Cognitively impaired • Cerebral palsy with normal cognitive level • Hearing or vision impaired • Non-English speaking • Intubated / paralyzed patients
- 31. Developmental Factors • Newborns and small children unable to give self-report • However, avoidance behavior has been shown by at least 6 months of age • Consistency of facial and cry response has been shown in neonates and infants • Children 3-5 yrs are able to use some self-report measures, localize pain
- 32. Assessment in Neonates • Neonatal Infant Pain Scale (NIPS) • Parent Report • Nurse Report • Physiologic Measures
- 35. Assessment in Infants and Children < 3 Years • OPS • CHEOPS • Parent Report • Nurse Report • Physiologic Measures
- 36. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) • Cry - None, Moaning, Crying, Screaming • Facial - Composed, Grimace, Smiling • Verbal - None, Other, Pain, Both, Positive • Torso - Neutral, Shifting, Tense, Shivering, Upright, Restrained • Touch - None, Reach, Touch, Grab, Restrained • Legs - Neutral, Squirming, Drawn-up, Standing, Restrained Pediatric Pain Management P R O G R A M
- 38. Assessment in Children 3-6 Yrs • Faces Scale • Oucher Scale • Poker Chip Tool • Visual Analogue Scale (VAS) • Observation Tools • Parent Report • Nurse Report
- 40. • Make sure the child has an understanding of number concepts and then teach the child to use the scale. • Point to each face and use the words under the picture to describe the amount of pain the child feels. • Then ask the child to select the face that comes closest to the amount of pain felt.
- 41. Faces Pain Scale • Make sure the child has an understanding of number concepts and then teach the child to use the scale. • Point to each face and use the words under the picture to describe the amount of pain the child feels. • Then ask the child to select the face that comes closest to the amount of pain felt.
- 43. Assessment in Children > 6-7 Yrs • Self-Report - VAS - Numerical Ranking Scale • Observational Scales • Parent Report • Nurse Report
- 45. Pain Indicator for Communicatively Impaired Children (PICIC) Most common cues identified by 67 parents: • Screwed up or distressed looking face • Crying with or without tears • Screaming, yelling, groaning, moaning • Stiff or tense body • Difficult to comfort or console • Flinches or moves away if touched
- 46. Observe for Improvement in Behavior Following an Analgesic
- 47. Observe for Improvement in Behavior Following an Analgesic
- 48. Secure Family’s Involvement • Take pain history before pain is expected, such as on admission to hospital or preoperatively • Involve family in recording response to pain relief measures
- 49. Secure Parents’ Involvement, cont.
- 50. Consequences of Pain • Cardiovascular and respiratory changes – Tachypnea, increased B/P and heart rate – Inadequate lung expansion, decreased arterial saturation – Inadequate cough • Neurologic changes – Fight /flight response- Tachycardia, insomnia, glucose • Metabolic changes – Increased fluid and electrolyte losses • Immune system changes – Depression of immune system with increase in risk for infection • Gastrointestinal changes – Increased intestinal secretions, prone to ileus
- 51. Pain Management • The presence of the parent is an important part of pain management. Children often feel more secure telling their parents about their pain and anxiety
- 52. Non-pharmacological Pain Management • Behavioral distraction • Assorted visuals • Breathing techniques • Comfort measure – Repositioning, holding – Touching, massaging – Warm or cold compresses • Diversional talk • Guided imagery • Biofeedback • Progressive muscle relaxation
- 53. Pharmacologic Interventions for Pain • Analgesics – Patient-controlled analgesia – Topical anesthetic cream • Non-steroidal anti-inflammatory drugs • Opioids • Conscious sedation • Epidural analgesia
- 54. Administering Analgesics to Children • The preferred routes are intravenous or oral. • Infants and children receiving IV and epidural opioids should be monitored by pulse oximetry. • If respiratory depression occurs with opioid use, naloxone hydrochloride should be used for reversal when oxygen and stimulation of the child are ineffective.
- 55. Nursing Interventions • When painful procedures are planned, use EMLA cream to anesthetize the skin where the painful stick will be made. • Procedure : – Apply a thick layer of cream over intact skin. – Cover the cream with a transparent adhesive dressing, sealing all the sides. • The cream anesthetizes the dermal surface in 45 to 60 min.
- 56. Take Cause of Pain into Account • Use common sense and logic. • Realize that for a an infant and small child, punctures are proportionally larger on their tiny bodies.
- 57. The only reason to assess pain is TO TAKE ACTION TO RELIEVE PAIN. After intervention, assess child’s response to pain relief measures. • Determine timing of assessment based on expected onset and peak effect of intervention: • IV analgesic: assess after 5 minutes and 15 minutes Take action and assess effectiveness
- 58. The Golden Rule What is painful to an adult is painful to an infant and child unless proven otherwise.
- 59. “Golden Rule” of Pain Assessment •Don’t forget to ask the patient !!!
- 60. You be the one to say: • The pain Stops here!!!!!!!!!