Chapter 39

• Pain

  Children, like adults, experience pain individually depending on the type and cause of the pain, their temperament, their previous experience with pain, and their expectation of relief

  
• Infants and young children

  • Cannot verbalize what they are feeling and so have the most difficulty communicating how they feel
• Children as young as 3 years of age

  • Can indicate by pointing to a body part where they feel pain
  • Can learn to express the degree of pain through a system such as comparing its intensity to a number of poker chips or drawings of faces
• Efficient pain control

  Anticipate when pain will occur and plan interventions to prevent it rather than let it occur and then relieve it

  
• Reasons why nurses and other pediatric providers may not provide adequate pain relief to children

  • Belief that infants and young children do not experience pain
  • Fear children will become addicted to pain relief medications
  • Fear of causing respiratory depression from analgesics
• Implementation for pain relief

  1. Choosing the specific method of pain relief that is best for each child

  2. Everyone involved in a child's care needs to be aware of the signs and symptoms that an individual child uses to express pain and specific ways that will help the child manage pain

  
• Outcome evaluation

  • No one pain relief measure is effective for everyone
  • After a child is given an analgesic, look for nonverbal clues, assess vital signs, and listen to the child's statements about pain to determine whether a drug was effective
  • Based on these findings, it may become clear that the technique of pain management being used may need to be modified or increased

  
• Acute pain in children

  • Usually occurs for one of four reasons: reduced pH alterations which cause depletion of oxygen in tissues, pressure on tissue, external injury, or overstretching of body cavities with fluid or air
• Chronic pain

  • Often involves irritation of nerves and/or tissue, which can occur with the pain of shingles, fibromyalgia, or other long-term injuries and irritations
• The stimulus causing pain is not always visible or measurable. In addition, anxiety can lead to increased pain regardless of the physical stimuli
• Pain conduction

  1. Transduction (sensing the pain sensation)

  2. Transmission (routing the pain sensation to the spinal cord)

  3. Perception (the brain interprets the sensation as pain)

  4. Modulation (steps the body takes to relieve pain)

  
• Pain threshold

  The point at which the child first senses pain. This varies greatly from person to person and is probably most influenced by heredity

  
• Pain tolerance

  The point above which a person is not willing to bear any additional pain. This is probably most affected by cultural influences
• Gate control theory of pain

  Envisions gating mechanisms in the substantia gelatinosa of the dorsal horn of the spinal cord that, when activated, can halt an impulse at that level of the cord and prevent the pain impulse from being received at the brain level and interpreted as pain
• Gating mechanisms can be stimulated by

  • Cutaneous stimulation
  • Distraction
  • Anxiety reduction
  • Nerve blocks
• Pain assessment with children

  • Can be difficult because children have difficulty describing pain
  • Some children will suffer with pain rather than report it, unaware that someone could make it go away
  • Some children may distract themselves by methods such as concentrating on play
  • Others may sleep, not from comfort but from the exhaustion caused by the pain
  • Cultural differences also influence how pain is expressed

  
• In the past, it was believed that infants do not feel pain because of incomplete myelination of peripheral nerves. Evidence-based practice has shown this not to be true because myelination is not necessary for pain perception
• In the past, another argument against needing to provide pain relief for infants was that they have no memory. However, it can be shown that physiologic changes occur with pain even in preterm infants, so even with a lack of memory, it is clear that pain is experienced

  
• Newborns

  • Instinctively guard a body part by holding an extremity still or tensing the abdomen
  • Other clues are diffuse body movements; tears; a high pitched, harsh cry; a stiff posture; alterations in facial expression such as eyes squeezed shut; a quivering chin; lack of play; and fisting
• Toddlers and preschoolers

  • May not have a word in their limited vocabularies to describe the sensation they feel because words such as "sharp," "nagging," or "aching" have little meaning until a child has experienced each type
  • Parents often encourage children of this age to refer to pain as "my boo-boo" or to use other word such as "hurt" or "ouchie"

  
• Preschool children

  • Can describe that they have pain but continue to have difficulty describing its intensity
  • Begin to use comforting mechanisms, such as gritting teeth, pressing a hand against a forehead, pulling on their ear, holding their throat, rubbing an arm, or grimacing, to control or express pain
  • May exhibit regression or withdrawal
• School-age children

  • Can have difficulty envisioning that a word like "sharp" applies both to knives and to the feeling in their abdomen
  • May assume, like preschoolers, that you, as an authority figure, already know they have pain
  • Guarding (tensing of body parts) is common
  • Sometimes, children can report they are fine while looking uncomfortable and being unwilling to move
• Adolescents

  • Are able to use adult pain scales for assessment
  • Commonly use adult mechanisms for controlling pain such as grimacing or verbal outbursts
  • Some try to be stoic or not show pain in order to avoid stereotypes of "crybaby" or "chicken"

  
• Pain assessment

  • Monitoring for physiologic findings such as a change in pulse or blood pressure may give some indication that a child is under stress, but these are not the most dependable indicators of pain because pain is a subjective symptom
  • Once children can speak, asking them to tell you about their pain (self-reporting or using a pain rating scale) becomes the most accurate method for assessment

  
• Pain rating scales

  • None have been proven to be consistently better than the others, mainly because both children and the type of pain they can be experiencing vary so much
  • Pick a well documented effective scale and urge your care team to use that consistently for each child rather than asking a child to adapt to different assessment techniques

  
• Pain Experience Inventory

  • A tool consisting of eight questions for children and eight questions for the child's parents
  • Designed to elicit the terms a child uses to denote pain and what actions a child thinks will best alleviate pain
  • Should be used before the child has pain, if possible

  
• CRIES Neonatal Postoperative Pain Measurement Scale

  • A 10-point scale named for five physiologic and behavioral variables commonly associated with neonatal pain
  • Infants with a total score of 4 or more are most likely to be in pain and need interventions to reduce discomfort
  • Cannot be used with infants who are intubated or paralyzed for ventilatory assistance

  
• COMFORT Behavior Scale

  • A pain rating scale devised by nurses to rate pain in very young infants
  • Rates six different categories (alertness, calmness/agitation, crying, physical movement, muscle tone, and facial expression) from 1 to 5
  • The lowest score is 6 (no pain), and 30 is the highest (a great deal of pain)
  • The infant is then observed for 2 minutes and the evaluation of the baby's pain is documented on an analog (1 to 10) visual scale

  
• FLACC Pain Assessment Tool

  • A scale by which healthcare providers can rate a young child's pain when a child cannot give input, there is a language barrier, or the child has a developmental delay
  • Incorporates five types of behaviors that can be used to rate pain: facial expression, leg movement, activity, cry, and consolability

  
• Poker Chip Tool

  • Uses four red poker chips placed in a horizontal line in front of the child
  • Can be used with children as young as 4 years of age, provided the child has some concept of "more" or "less"
  • The child points to the chip that represents their current level of pain
• Wong-Baker FACES Pain Rating Scale

  • Consists of six cartoonlike faces ranging from smiling to tearful
  • Each face from left to right corresponds to a person who has no hurt up to a lot of hurt
  • Can be used for children as young as 3 years of age

  
• Oucher Pain Rating Scale

  • Consists of six photographs of children's faces representing "no hurt" to "biggest hurt you could ever have"
  • Also includes a vertical scale with numbers from 0 to 100

  
• Numerical or visual analog scale

  • Uses a line with end points marked "0 = no pain" on the left and "10 = worst pain" on the right
  • Divisions along the line are marked in units from 1 to 9
  • Explain to children that the left end of the line (0) means that a person feels no pain, and the right end (10) means the worst pain possible
• Numerical or visual analog scale

  Line with end points marked "0 = no pain" on the left and "10 = worst pain" on the right, with divisions along the line marked in units from 1 to 9
• Explain to children

  The left end of the line (0) means that a person feels no pain. At the other end is a 10, which means that a person feels the worst pain possible. The numbers 1 to 9 in the middle are for "a little pain" to "a lot of pain."
• Ask children

  To choose a number that best describes their pain

  
• Adolescent Pediatric Pain Tool (APPT)

  Combines a visual activity and a numerical scale. On one half is an outline figure showing the anterior and posterior view of a child. On the right side is a scale for rating present pain in reference to "no pain," "little pain," "medium pain," "large pain," and "worst possible pain." Children can also point to or circle words that describe their pain.

  
• Logs and diaries

  Having children keep records of when pain occurs and the intensity, which can be useful for assessing children with chronic but intermittent pain

  
• Pain management techniques

  Vary greatly depending on the age of a child and the degree and type of pain a child is experiencing

  
• Pharmacologic pain relief


  Administration of a wide variety of analgesic medications, which can be applied topically or given orally, intramuscularly, intravenously, or by epidural injection