Child Health Nursing Partnering with Children & Families Chapter 18 Pain Assessment and Management Jane W. Ball Ruth C. Bindler Child Health Nursing: Partnering.
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Acute Pain- the History !Acute Pain- the History !
• Before 1970 - no formal research looking at pain management in children
• Swafford and Allen,1968: “pediatric patients seldom need medication for pain relief”
• 1974 – 13/25 children received no analgesia after surgery such as nephrectomies, palate repairs and traumatic amputations
Do children feel pain?Do children feel pain?• Pain fibers present at end of 2nd
trimester• Increased heel sensitivity post heel
sticks• Crying increases for days post
circumcision• 6 month olds-anticipate and avoid
pain
What is Pain?What is Pain?• “Pain is whatever the experiencing
person says it is, existing whenever they say it does”
(McCaffery and Pasero, 1999)
What is pain?What is pain?• " Pain is an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It may be acute or chronic.
• Pain is always subjective. Enormous individual differences in response to painful stimuli exist.
• (from The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSMPC)
• Child and Adolescent Version, American Academy of Pediatrics,1996.)
What is Pain?What is Pain?• The pain stimulus is interpreted
based on the context or meaning of the pain to the individual, as well as the individual's psychological state, culture, previous experience, and a host of other psychosocial variables.
What is Pain?What is Pain?• As a result, the same noxious
stimulus may cause different amounts of pain in different individuals based on personal characteristics." – (from DSM-PC) Child and Adolescent
Version, American Academy of Pediatrics, 1996.)
Let’s review what is PainLet’s review what is Pain• Pain is a signal,
– nothing more,– nothing less
• ALL PAIN IS REAL• PAIN is PAIN,• Suffering is
Optional!
Pathophysiology of PainPathophysiology of Pain• Acute vs Chronic
Pain– What is Acute Pain?
• brief duration: usually less than 3 months
• Identifiable cause / injury / surgery or disease
• predictable end• subsides with
healing
Pathophysiology of PainPathophysiology of Pain• Acute vs Chronic
– What is chronic pain?• Peristent pain
lasting longer than 6 months that is generally associated with a prolonged disease process
Pathophysiology of PainPathophysiology of Pain• Nociceptors
– Free nerve endings at site of tissue damage– Purpose of nociceptors are to transmit pain
impulses along specialized nerve fibers,• the A-delta and C-fibers, to the dorsal horn of the
spinal cord
• Substantial gelatinosa, aka “gate-keeper”– Regulates transmission of pain and other nerve
impulses to the CNS– Located in the dorsal horn of s.c.
Pathophysiology of PainPathophysiology of Pain
Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families
• Acronym for face, legs, cry and consolability – Body Outline (3 and over)
Oucher Pain ScaleOucher Pain Scale
Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families
– Let’s say 0 means no pain and 10 means the worst pain anyone could have. How much pain do you have? (score 0-10)
Assessing Readiness for Use Assessing Readiness for Use of Pain Scalesof Pain Scales
• Refer to Box 18-3• Assess a chlid’s language, and
understanding of concepts• Children 2-3 years-old
– Understand more or less– No more than 3 choices on pain scale
• Only 26% of 5 year olds understand numeric scale– Which number is smaller 4 or 7?
Children with CognitiveChildren with CognitiveImpairmentImpairment
• Assessment of pain difficult• Contribute to inadequate analgesia• Merkel et al (1997)
– FLACC scale validated for cognitively impaired children
Case StudyCase Study• Tom is 10 years old and has severe
mucositis after having a BMT. He has a morphine PCA with a background infusion of 1ml/hr. He is lying very still in bed and is very reluctant to move. His mum does not want him to push the button unless he is really sore, as she has heard that morphine is really addictive.– Who is the best judge of Tom’s pain?– How would you go about assessing Tom’s
• A method of administering IV or epidural analgesic using a computerized pump that is programmed by a healthcare professional and controlled by the child
• Children 5 years and older• Children should be able to push the button
and understand that this will give them pain relief.
Non-pharmacologic Methods Non-pharmacologic Methods of Pain Controlof Pain Control