NURS 3450 Ch 9 ATI Pediatric Pain Management

Children of what age can perceive pain?
All ages
Unrelieved pain is a major _____ and _____ stressor.
Physiologic, psycologic
What can repeated pain in infants lead to?
Future sensitivity to pain
What can self-protective behavior due to pain cause?
Delayed healing
List pain behaviors for acute pain.
Short attention span, irritability, grimacing, posturing, limb flexion, sleep disturbances, lethargy, withdrawal
List pain behaviors for chronic pain.
Physiologic adaptation may mask signs
How should a developmentally appropriate pain scale be chosen?
Determine child’s ability to demonstrate concepts of degree, rank order, estimation, and classification
List the 6 types of self-report scales.
-Body outline
-Faces
-Oucher
-Poker chip
-Numeric rating
-World-graphic rating
List the factors that can have a positive or negative effect on pain perception.
-Age
-Developmental stage
-Chronic or acute disease
-Socioeconomic status
-Prior experiences with pain
-Personality
-Family dynamics
-Culture
A loud cry is a developmental characteristic of pain in what age group?
Young infant and older infant
A rigid body/thrashing is a developmental characteristic of pain in what age group?
Young infant
A local reflex withdrawal from a painful stimulus is a developmental characteristic of pain in what age group?
Young infant
Lowered and drawn together eyebrows are a developmental characteristic of pain in what age group?
Young infant
Tightly closed eyes are a developmental characteristic of pain in what age group?
Young infant
An open mouth in a squarish shape is a developmental characteristic of pain in what age group?
Young infant
A facial expression of pain is a developmental characteristic of pain in what age group?
Older infant
Deliberate withdrawal from pain is a developmental characteristic of pain in what age group?
Older infant
A loud cry/scream is a developmental characteristic of pain in what age group?
Toddler; school age
Verbal expression of pain is a developmental characteristic of pain in what age group?
Toddler; School age
Thrashing of extremities is a developmental characteristic of pain in what age group?
Toddler; school age
Attempt to push away or avoid a painful stimulus is a developmental characteristic of pain in what age group?
Toddler; school age
Noncooperation is a developmental characteristic of pain in what age group?
Toddler; school age
Clinging to a significant person is a developmental characteristic of pain in what age group?
Toddler; school age
What is the main difference between developmental characteristics of pain in toddlers and school age?
-Toddler: behaviors occur in anticipation of painful stimulus
-School age: behaviors are less intense in the anticipatory phase and more intense with painful stimulus
Stalling behavior is a developmental characteristic of pain in what age group?
School age
Muscular rigidity is a developmental characteristic of pain in what age group?
School age
Verbal expression of pain with less protesting is a developmental characteristic of pain in what age group?
Adolescent
Muscle tension with body control is a developmental characteristic of pain in what age group?
Adolescent
What is the minimum age to use self report pain scales?
4 years
What assessment tool is appropriate for children >3 years old?
FACES
What assessment tool is appropriate for children 2 months-7 years?
FLACC
What assessment tool is appropriate for children aged 3 years to 13 years
Oucher
What is the minimum age to use a numeric scale to rate pain?
5 years
What assessment tool is appropriate to use for non-communicating children aged 3-18 years?
Non-communicating child’s pain checklist
How does the FLACC work?
Pain is rated by the healthcare professional on a scale of 0-10 by assessing behaviors of the child in 5 categories.
What does F stand for in FLACC?
Face
If a child scores a 0 for the F component of the FLACC assessment, what does this mean?
They have a smile or no expression
If a child scores a 1 for the F component of the FLACC assessment, what does this mean?
They occasionally frown or grimace, may look withdrawn
If a child scores a 2 for the F component of the FLACC assessment, what does this mean?
They frequently or constantly frown, have a clenched jaw, or a quivering chin
What does L stand for in FLACC?
Legs
If a child scores a 0 for the L component of the FLACC assessment, what does this mean?
Relaxed or normal position
If a child scores a 1 for the L component of the FLACC assessment, what does this mean?
Uneasy, restless, tense
If a child scores a 2 for the L component of the FLACC assessment, what does this mean?
Kicking or legs drawn up
What does the A stand for in FLACC?
Activity
If a child scores a 0 for the A component of the FLACC assessment, what does this mean?
Lying quietly ,moves easily, normal position
If a child scores a 1 for the A component of the FLACC assessment, what does this mean?
Squirmy, shifting, tense
If a child scores a 2 for the A component of the FLACC assessment, what does this mean?
Arched, rigid, jerking
What does the first C stand for in FLACC?
Cry
If a child scores a 0 for the first C component of the FLACC assessment, what does this mean?
No cry
If a child scores a 1 for the first C component of the FLACC assessment, what does this mean?
Moans or whimpers, occasional complaints
If a child scores a 2 for the first C component of the FLACC assessment, what does this mean?
crying, screaming, sobbing, frequent complaints
What does the second C in FLACC stand for?
Consolability
If a child scores a 0 for the second C component of the FLACC assessment, what does this mean?
Content or relaxed
If a child scores a 1 for the second C component of the FLACC assessment, what does this mean?
Reassured by occasional touching or hugging, able to distract
If a child scores a 2 for the second C component of the FLACC assessment, what does this mean?
Difficult to console or comfort
How is pain assessed with the FACES scale?
Child is shown 6 faces of varying degrees of pain; Provider explains each face to the child and asks them to choose a face that best describes how they are feeling; Pain is rated by the child on a scale of 0-5; provider translates that score into 0, 2, 4, 6, 8, or 10
What does a 0 indicate on the faces scale?
no hurt
What does a 1 indicate on the faces scale?
Hurts a little bit
What does a 2 indicate on the faces scale?
Hurts a little more
What does a 3 indicate on the faces scale?
Hurts even more
What does a 4 indicate on the faces scale?
Hurts a whole lot
What does a 5 indicate on the faces scale?
Hurts worst
Which assessment tool has the same premise as FACES?
oucher
Should a parent or caregiver be included in rating a childs pain?
Yes
While using the non-communicating child’s pain checklist, how long should the provider observe the childs behaviors for?
1o minutes
What are the six subcategories of behavior that a provider observes while using the non-communicating childs pain checklist?
-Vocal
-Social
-Facial
-Activity
-Body and limbs
-Psychological
What does a score of 0 in each category of the non-communicating childs pain checklist indicate?
child is not at all displaying the behaviors that indicate pain
What does a score of 1 in each category of the non-communicating childs pain checklist indicate?
Child is displaying the behaviors that indicate pain just a little bit
What does a score of 2 in each category of the non-communicating childs pain checklist indicate?
Child is displaying the behaviors that indicate pain fairly often
What does a score of 3 in each category of the non-communicating childs pain checklist indicate?
Child is displaying the behaviors that indicate pain very often
What does an overall score of 6-10 on the non-communicating childs pain checklist indicate?
Mild pain
What does an overall score of >11 on the non-communicating childs pain checklist indicate?
moderate to severe pain
What factor is highest on the hierarchy of assessment strategies?
Subjective report of pain
What factor is second highest on the hierarchy of assessment strategies?
Painfulness of procedure
What factor is third highest on the hierarchy of assessment strategies?
Parents perspective
What factor is fourth on the hierarchy of assessment strategies?
Behavioral cues
What factor is fifth on the hierarchy of assessment strategies?
Reason to suspect pain; relief with analgesics
What factor is lowest on the hierarchy of assessment strategies?
Contributing situational factors
What does rubor mean?
redness
What does calor mean?
heat
What does tumor mean?
swelling
What does dolor mean?
Pain
What types of crying typically indicate pain?
-High pitched
-Tense
-Harsh
-Non-melodious
-Short
-Sharp
-Loud
What does a bulge between the eyes and vertical furrows indicate?
Pain in an infant
What do raised cheeks indicate in an infant?
Pain
What does a broadened and bulging nose in an infant indicate?
Pain
What are the four major categories of drugs given to children for pain?
-Opiods
-Non-opiods
-Anesthetics
-Adjuvants/ co-analgesics
What are the 5 major non-opiods given to children?
-Acetaminophen
-Aspirin
-NSAIDS: Ibuprofen, Cox 2 inhibitors, ketoralac (Toradol)
What are the 7 major opiods given to children?
-Fentanyl
-Morpine
-Hydromorphone
-Methadone
-Codeine
-Hydrocodone
-Oxycodone
Should acetaminophen be given for post operative pain?
No
Should acetaminophen be given for a migraine?
No
Should acetaminophen be given for vaccination prophylaxis?
No
What are the two appropriate routes to administer acetaminophen?
PO or IV
What is the appropriate dosage of acetaminophen for a child?
10-15 mg/kg every 4-6 hours
In 28-32 weeks gestation, what is the appropriate dosage interval for acetaminophen?
8-12 hours
What does the CRIES scale measure?
C-Crying
R-requires O2 for saturation >95
I- increased vital signs
E-expression
S-sleepless
What does PIPP stand for?
Premature infant pain profile
What does NIPS stand for? What does it measure?
Neonatal infant pain scale
-Expression, cry, breathing, arm and leg movements, arousal state
What does DSVNI stand for?
Distress scale for ventilated newborn infants
List the 4 major multidimensional infant pain scales.
-CRIES
-PIPP
-NIPS
-DSVNI
What do the multidimensional infant pain scales measure?
-The intensity of pain-related distress and pain reactivity
What are the multidimensional infant pain scales best used for?
To assess procedural pain, rather than ongoing pain assessments
What is the minimum age requirement for ibuprofen?
6 months
What is the appropriate dosage for ibuprofen for a child?
4-10 mg/kg/dose every 6-8 hours
Should ibuprofen be administered for vaccinaiton prophylaxis?
No
What is the only NSAID approved for pain by the FDA for children under the age of 12 years?
Ibuprogen
What should be given for mind to moderate pain?
Tylenol, aspirin, NSAIDS
What should be given for moderate to severe pain?
Opiods
Should codeine be administered for sickle cell crisis?
No
What is the minimum age requirement for codeine?
2 years
What is the maximum daily dose for codeine?
3mg/kg
What is the typical route and dosage for codeine?
.5-1mg/kg/dose every 4 to 6 hours PRN
What is the most prescribed opioid for children?
Codeine
What oral opioid causes the most nausea?
Codeine
What must happen for codeine to be relieve pain?
It is a pro-drug: it must be metabolized to morphine to relieve pain
Should morphine be given to treat post operative pain?
Yes
Should morphine be given to treat cancer pain?
Yes
Should morphine be given to treat chronic pain?
Yes
Should morphine be given to treat neuropathic pain?
No
Should morphine be given through a PCA?
No
Should morphine be given for sickle cell crisis?
No
Should morphine be given to premature infants?
No
What is the gold standard for opioid analgesics?
Morphine
What is the maximum morphine dose?
-Use second dose every hour if needed with good pain relief and minimal sedation
-Maximum dose is the one that results in intolerable side effects
How can morphine be given?
PO, IV, IM, SQ
What is the typical dosage of morphine when used IM, IV, or SC?
.1-.2 mg/kg q2-4 hr
What is the maximum dose of morphine when given IM IV or SC?
15mg/dose or 05-.1 mg/kg
What is the typical continuous IV infusion rate of morphine for postoperative pain in children 1-15 years?
.02 mg/kg/hr
What is the typical dosage of morphine when administered PO?
.2-5 mg/kg/dose Q4-6 hrs PRN
What is the minimum age requirement for fentanyl?
2 years
Under what circumstances should the oral transmucosal form of fentanyl be administered?
For procedural pain
What are the three routes that fentanyl should be given to treat post operative pain?
-Epidural
-PCA
-Continuous infusion
What is the dosage of fentanyl for continuous infusion in a neonate?
1mcg/lg IVP
What is the dosage of fentanyl for continuous infusion in a ventilated neonate?
2-5mcg/kg/hr
Which form of fentanyl oral transmucosal is appropriate for children over 2 years of age: oralet or actiq?
Oralet
Should meperidine be given for migranes?
No
Should meperidine be given for sickle cell crisis?
No
Should meperidine be given for chronic pain?
Yes
Should meperidine be given through a PCA?
Yes
What should meperidine (demerol) be reserved for?
For very brief courses in patients who have a demonstrated allergy or intolerance to other opiods
What is the toxic metabolite of meperidine? What can it cause?
Normeperidine- a cerebral irritant and accumumulation can lead to seizures in otherwise healthy persons
Should ketorolac be administered for fracture reduction pain?
no
Should ketorolac be administered for narcotic sparing effect?
No
Should ketorolac be administered for headache?
No
What is the minimum age requirement for ketorolac?
16 years
What is the typical dosage of ketorolac?
.5mg/kg IV q 6 hrs for 48 to 72 hours with analgesics for moderate to severe pain
Is methadone approved for use in children?
No
What is the typical dosage of methadone?
.2mg/kg q 6 hrs
What is the dosage of oral methadone for continuous pain, as seen in trauma?
.3-.4 mg/kg/day divided into several doses
Is hydromorphone approved for use in children?
No
Should hydromorphone be used for analgesia?
No
What is the typical dosage of hydromorphone for children?
.05-.1mg/kg/dose PO q hr
What is the typical dosage of hydromorphone for adolescents?
1-2mg/dose IV q 4-6 hrs
Is hydrocodone approved for children?
No
Should oxycodone be used for postoperative pain?
No
Should oxycodone be used for back pain?
No
Should oxycodone be used for dental pain?
No
Should oxycodone be used for neuropathic pain?
No
Is oxycodone approved for use in children?
No
What is the typical oxycodone dosage?
.05-.15 mg/kg, up to 5mg per dose, q 4-6 hr
Opioid side effects are often related to what?
Dose
Does tolerance to opioid side effects occur?
Yes, except to constipation
What are the frequent side effects of opioids?
-N, V, C
-Sedation
-Mental clouding
-Pruritis
What are the less frequent side effects of opioids?
-Myoclonus (jerky contractions)
-Urinary retention
-Delerium
What are the adverse effects of opioids?
Respiratory depression, cardiovascular collapse, addiction
What respiratory rate in children qualifies as respiratory depression?
<12 bpm
How often should vital signs be checked during a painful procedure?
q 15 minutes
What should be assessed after a procedure involving sedation or analgesia?
-CV and respiratory function
-Arousability
-Hydration
-Protect from injury
What percentage of individuals treated for pain become addicted to opioids?
<1%
What percentage of the american population is currently addicted to drugs?
6-15%
From 1992 to 2001, what happened to the treatment admission rate for opioid addiction?
Doubled
From 1992 to 2001, that happened to the emergency room visits related to opioid abuse?
Increased by 117%
What are the appropriate routes to give opioids to children? which of these should be avoided if possible?
IM IV Oral; avoid IM
Should pain medications be given routinely or PRN?
Routinely to manage pain that is expected to last for an extended period of time
Should children <18 years old receive intranasal medications?
No
Why should rectal administration of drugs be avoided in children, if possible?
Absorption rates vary and kids dislike them
Where should painful procedures take place?
-In treatment room
-Away from safe places like bed
When should IV medications be given?
For severe pain of sudden onset
When should oral pain medications be administered?
As soon as the patient can tolerate oral intake
Why are oral pain medications preferred?
They have a longer duration of analgesia than parenteral route; decreases peaks and valleys of pain and pain releif
What does PRN stand for?
Pro Re Nata (as necessary)
What patients are at greatest risk for opioid related respiratory depression?
Smallest
Which patients should be started on 1/4 to 1/2 of the initial recommendations of pain medication and titrated up as needed?
<6 months <10 kg History of apnea
What dosage of medication should a child >50kg receive?
Adult dosage: DO NOT calculate mg/kg
Do opioids have an analgesic ceiling?
No
What is the pattern for respiratory depression from opioids?
-Decreased LOC
-Decreased depth of respiration
-Decreased RR
-Decreased O2 sat
How long does it typically take oral medications to reach peak analgesic effects?
1-2 hrs
What topical medication contains lidocaine and prilocaine in the form of a cream or disk?
ELMA
When should ELMA be applied for a superficial procedure such as IV insertion or biopsy?
60 mins before
When should ELMA be applied for a deep puncture?
2.5 hrs before
What type of dressing should be applied over ELMA?
Occlusive
Prior to the procedure, what should the nurse do with ELMA?
Clean the skin and check for adequate response, demonstrate to child that skin is not sensitive by lightly scratching or tapping
What indicates an adequate response to ELMA?
Redened, blanched skin
What are the advantages of using a PCA?
-Adjusts for individual variation in kinetics and dynamics
-Gives a sense of control
-Avoids bargain and begging
-Safe and effective
What are the disadvantages of using a PCA?
-Expense ($88/day)
-Anyone can push the button
-Push the button or suffer
-May not completely relieve pain
-Not a panacea: side effects still persist
What is the minimum age for a PCA?
7 years
What are the requirements for a PCA?
-Able to push button
-Able to quantify pain
-Unable to tolerate oral analgesics
-Understand the relationship between pushing the button and medication delivery
-Understand the safety mechanisms of the machine
-Report unsatisfactory pain relief
What is the major advantage of using epidural analgesia?
Provides good to excellent analgesia with less side effects than with the use of systemic opioids:
-Infrequent nausea
-Minimal sedation
-Earlier ambulation
-Retention of cough reflex
-Decreased pulmonary dysfunction
-Decreased neuroendocrine and metabolic response to surgical stress
What are the disadvantages of epidurals?
-Expense and availability
-Parents and caregivers often feel that if the child is not receiving adequate relief of pain from the epidural medication there is noting more that can be done; child and family may not report pain that is not completely relieved
-Infrequent use has led to misconceptions and fear with use
Epidural use is appropriate for which types of patients?
-Open heart surgery
-Abdominal procedures
-Anal or urogenital procedures
-Orthopedic surgeries of the lower limbs
-Thoracic surgeries
-Cancer pain
-Pancreatitits
For which patients is epidural contraindicated?
-Vertebral anomalies that would make catheter placement difficult
-Coagulopathies that may make the child at an increased risk for epidural hematomas
-Systemic infections
If a child receiving an epidural has a temperature spikes, why must the physician be notified?
The epidural catheter in a child with an active systemic infection can be a conduit to the CSF- and a meningitis may result
What nonpharmacological measures can be taken to decrease pain?
-Distraction (play, joke, radio, movies, computer games, telling stories)
-Relaxation (holding, breathing)
-Guided imagery
-Positive self talk
-Behavioral contracting with rewards
-Containment
-Nonutritive sucking
-Kangaroo care
-COmplemetnary and alternative medicine
-Massage
-Chiropractic options
-Heat/cold
-Aromatherapy
-Hypnosis
-TENS units
List topical anesthetics appropriate for use with children.
-EMLA
-Pain ease (vapocoolant)
-Numby stuff
-Lidosite
-LMX4
-Synera
-J tip
Explain the gate control theory.
-Inhibitory neuron stimulation reduces pain sensation
-Distractions and stimulations can enhance effects of analgesics
What position should an infant be held in to give an oral medication?
Semi-reclining
What position should a small child be held in to give an oral medication to prevent aspiration?
Upright
How should liquid oral medications be administered to children?
In side of mouth in small amounts to allow swallowing
If a child does not like the taste of an oral medication, what should the nurse instruct them to do?
Hold their nose
What can a nurse do to promote swallowing of oral medication in an infant?
Stroke under chin and hold cheeks together