and Management in Children - · PDF fileDevelop a nursing care plan for assessing and ... Pain Assessment and Management in Children 1209 ... hypertension, pupil dilation, pallor,

www.prenhall.com/londonMEDIALINK

42Pain Assessmentand Management

in Children

CHAPTER

Felicia must be in pain so soon after her surgery. I know I would have painif it were me. Can she get pain medicine without getting another needle?

—Mother of Felicia, 5

LEARNING OBJECTIVES

1207

■ Assess children of different ages with acute painand develop a nursing care plan that integratespharmacologic interventions anddevelopmentally appropriate nonpharmacologic(complementary) therapies.

■ Develop a nursing care plan for assessing andmonitoring the child having sedation and analgesiafor a medical procedure.

CD-ROM

NCLEX-RN® ReviewAnimation: MorphineVideos:

Pain Management KitPain Perception

Nursing in Action: Administering Patient-ControlledAnalgesia

Nursing in Action: Sedation MonitoringPostoperative Pain Flow ChartAudio GlossarySkill 13-1 Selected Pediatric Pain ScalesSkill 13-2 Patient-Controlled AnalgesiaSkill 13-3 Monitoring SedationSkill 13-4 Local Pain Blocks

Companion Website

NCLEX-RN® ReviewCase StudyThinking CriticallyMediaLink Applications:

Managing Light SedationCalculating Opioid DosagePostoperative Pain Assessment

Complementary Care: Hypnotherapy for Children

■ Describe the physiologic and behavioralconsequences of pain in children.

■ Select an appropriate tool to assess the pain ofinfants and children in each age group.

■ Describe the nursing assessment and managementfor a child receiving an opioid analgesic.

■ Explain the rationale for the effectiveness ofnonpharmacologic (complementary) methods ofpain control.

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1207

Everyone has his or her own perception of pain. A neurologic responseto tissue injury, pain is an unpleasant sensory and emotional experi-ence associated with actual or potential tissue damage (see “Patho-

physiology Illustrated”). Effective pain management is every child’s right.

ACUTE AND CHRONIC PAINPain exists when the patient says it does (McCaffrey & Pasero, 1999). Painmay be either acute or chronic. Acute pain is sudden and of short duration;it may be associated with a single event, such as surgery, or an acute exacer-bation of a condition such as a sickle cell crisis. The inflammatory responsethat follows the initial tissue injury causes a sustained pain response (Fuller,2001). Chronic pain is a persistent pattern of pain, lasting longer than 6months; it is generally associated with a prolonged disease process such asjuvenile rheumatoid arthritis.

In 2001 the Joint Commission on Accreditation of Healthcare Organi-zations introduced standards for the assessment and management of pain inpatients. All patients are assessed for pain, and they have the right to appro-priate pain management. Patient education includes managing pain as a partof treatment.

MISCONCEPTIONS ABOUT PAIN IN CHILDRENHealthcare professionals once believed that children feel less pain thanadults. Undertreatment of pain was based on these attitudes about pain, thedifficulty and complexity of pain assessment in children, and inadequate re-search. Some nurses still undertreat pain, either not giving pain medicationon a fixed schedule around the clock as ordered by the physician or givingless than 40% of the pain medication ordered (Vincent, 2001). For a reviewof past myths and the contrasting reality, see Table 42–1.

Research has shown that past beliefs about children’s perception of painwere incorrect. Even newborns feel pain. All the necessary peripheral andcentral nervous system anatomic structures and functional ability to processpain are present by 20 weeks’ gestation (Pasero, 2002). Pain impulses aretransmitted along the nonmyelinated C fibers, and the pain signal is less pre-cise. Pain conduction may be slower in newborns, but the distance the painstimuli must travel is much shorter than in adults. Because the descendingneurotransmitters are less developed, newborns are less able to reduce thepain impulses. Premature and newborn infants may be even more sensitiveto pain than older children. Newborns and infants also remember pain. By 6months of age, children demonstrate anticipatory fear of pain when taken toa location where they once experienced pain (McGrath & Craig, 1989).

Acute pain, 1208

Anxiolysis, 1227

Chronic pain, 1208

Deep sedation, 1227

Distraction, 1224

Electroanalgesia, 1225

Equianalgesic dose, 1216

Light sedation, 1227

Nonsteroidal anti-inflammatory drugs(NSAIDs), 1215

Opioids, 1215

Pain, 1208

Patient-controlled analgesia (PCA), 1219

Tolerance, 1223

Withdrawal, 1217

KEY TERMS

1208

DEVELOPING CULTURAL COMPETENCE

HEALTH PROFESSIONAL’S ATTITUDES ABOUT CHILDREN’S PAIN

Think about your personal pain experiences during childhood and how your family membersencouraged you to be stoic or to express pain. These types of experiences often contributeto a health professional’s attitudes about pain experienced by children. For example, health-care workers may believe that being in pain for a little while is not so bad or that pain helpsbuild character.

MED

IALI

NK

JCAH

O

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1208

Pain Assessment and Management in Children 1209

CLINICAL MANIFESTATIONS

Physiologic IndicatorsAcute pain stimulates the adrenergic nervous system andresults in physiologic changes, including tachycardia,tachypnea, hypertension, pupil dilation, pallor, increasedperspiration, and increased secretion of catecholaminesand adrenocorticoid hormones. Changes in these signsdemonstrate a complex stress response. These signs are notspecific to pain, so they cannot be used for monitoring pain.

Chronic pain of long duration permits physiologicadaptation, so normal heart rate, respiratory rate, andblood pressure levels are often seen (Huether & Leo, 2002).

Behavioral IndicatorsChildren in acute pain behave in many of the same ways aschildren who show signs of fear and anxiety (Hazinski,1999; Tesler, Holzemer, & Spreker, 1999). These behaviorsinclude the following:

■ Short attention span (child is difficult to distract)

■ Irritability (child is difficult to comfort)

■ Facial grimacing, biting or pursing lips; see Figure 42–1 on p. 1211 for facial expression ofnewborns and infants

■ Posturing (guarding a painful joint by avoidingmovement), remaining immobile, or protecting thepainful area

■ Drawing up knees, flexing limbs, massaging affected area

■ Lethargy, remaining quiet, or withdrawal

■ Sleep disturbances

Preverbal children may show conflicting signs of pain(restlessness, agitation or withdrawal, hyperalert or vigi-lant, grimacing, crying, or anger), making pain assessmentand management more challenging.

Children often suffer additional emotional distress andfear that the discomfort will worsen. Depression and aggres-sive behavior are frequently overlooked as indicators of pain.

CONSEQUENCES OF PAINUnrelieved pain is stressful and has many undesirablephysiologic consequences (Table 42–2). For example, the

Pain perception point

Lateralspinothalamic tract

Nociceptors(painreceptors)

A-delta fibers(fast transmission ofsharp, localized pain)

Spinal ganglia

Dorsal horn; location of Substantia gelatinosa(pain signal modified)

C fibers(slow transmissionof dull, burning, chronic pain)

1

3

4

5

2

Pain PerceptionPain Perception

Nociceptors (free nerve endings at the site of tissue damage)transmit information by specialized nerve fibers to the spinalcord. Unmyelinated C fibers slowly transmit dull, burning, dif-fuse pain as well as chronic pain. Large, myelinated A-deltafibers quickly transmit sharp, well-localized pain. Nociceptorsare stimulated by mechanical, thermal, and chemical injury.Biochemical mediators (bradykinin, prostaglandin, leukotri-enes, serotonin, histamine, catecholamines, and substance P)are produced in response to tissue damage. These substanceshelp move the pain impulse from the nerve endings to thespinal cord. After the sensory information reaches the substan-tia gelatinosa in the dorsal horn of the spinal cord, the pain sig-nal may be modified depending on the presence of otherstimuli, from either the brain or the periphery. The pain signal isthen transmitted to the brain through the spinothalamic, retic-ulospinal, and spinomesoencephalic nerve pathways, whereperception occurs. Once the sensation reaches the brain, emo-tional responses may increase or decrease the intensity of thepain perceived.

The gate control theory of pain helps explain how the painimpulses are allowed to proceed to the brain. The substantiagelatinosa serves as a gate and regulates the transmission ofpain and other impulses to the brain (Huether & Leo, 2002).Since pain and nonpain impulses are sent along the samepathways, nonpain impulses can compete with pain impulsesfor transmission.

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1209

1210 CHAPTER 42

child with acute postoperative pain takes shallow breathsand suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratorycomplications. Unrelieved pain may also delay the returnof normal gastric and bowel functions and cause a stressulcer. Anorexia associated with pain may delay the healingprocess. The long-term effects of pain on the child’s physi-cal or psychologic condition are unknown.

PAIN ASSESSMENTThe goal of pain assessment is to provide accurate informa-tion about the location and intensity of pain and its effects onthe child’s functioning. No laboratory tests are routinely usedto assess pain. Prolonged, severe pain produces a physiologicstress response that includes the chemical release of cate-cholamines, cortisol, aldosterone, and other corticosteroids.

Insulin secretion also decreases, leading to increased amountsof glucose and severe hyperglycemia (Hazinski, 1999).

PAIN HISTORYParents can provide a great deal of information about thechild’s response to pain, such as the following:

■ How the child typically expresses pain, both verballyand behaviorally. Children and parents use similarterms to describe pain. Some examples of words usedare a hurt, owie, boo-boo, stinging, sore, cutting, burning,itching, hot, and tight. Knowing the appropriate wordto use makes communicating with the child easier. Theparent can often provide signs used to recognize thechild’s pain.

■ The child’s previous experiences with painfulsituations and reactions.

Myth Reality

Newborns and infants are incapable of feeling pain. Children do notfeel pain with the same intensity as adults because a child’s nervoussystem is immature.

Infants are incapable of expressing pain.

Infants and children have no memory of pain.

Parents exaggerate or aggravate their child’s pain.

Children are not in pain if they can be distracted or if they aresleeping.

Repeated experience with pain teaches the child to be more tolerantof pain and cope with it better.

Children tolerate discomfort well. They become accustomed to painafter having it for a while.

Children recover more quickly than adults from painful experiencessuch as surgery.

Children tell you if they are in pain. They do not need medicationunless they appear to be in pain.

Children without obvious physical reasons for pain are not likely tohave pain.

Children run the risk of becoming addicted to pain medication whenused for pain management.

TABLE 42–1 Misconceptions about Pain in Infants and Children

By 20 weeks’ gestation, a fetus has most of the anatomic andfunctional requirements for pain processing. Term infants have thesame level of sensitivity to pain as older infants and children. Preterminfants may actually have greater sensitivity.

Infants express pain with both behavioral and physiologic cues thatcan be assessed.

Preterm infants have been noticed to associate the smell of alcoholwith heel sticks and to try to pull the foot away to avoid the pain.Infants cry in anticipation of immunizations.

Parents know their child and are able to identify when the child is inpain.

Children use distraction to cope with pain, but they soon becomeexhausted when coping with pain and fall asleep.

Children who have more experience with pain respond more vigorouslyto pain. Experience with pain teaches how severe the pain canbecome.

Children do not tolerate pain any better than adults, and may have lesstolerance with prior painful experiences. They do not becomeaccustomed to pain or cope with it better than adults.

Children heal quickly from surgery, but they have the same amount ofpain from surgery as an adult.

Children may be too young to express pain or afraid to tell anyoneother than a parent about the pain. The child fears the treatment forpain may be worse than the pain itself.

The cause of pain cannot always be determined. The feeling of pain issubjective and should be accepted by nurses.

Addiction is extremely rare when the child is treated for an acutecondition.

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1210


■ How the child copes with and manages pain. The childwith several past pain experiences may not exhibit thesame types of stressful behaviors as the child with fewpain experiences.

■ What works best to reduce the child’s pain?

■ The parent’s and child’s preferences for analgesic useand other pain interventions.

Bulged brows

Eyes squeezed shut

Furrowed nasolabialcreases

Taut tongue

Open, angular, squarishlips and mouth

Quivering chin

Brows lowered, drawn together

Neonatal characteristic facial responses to pain include bulged brow, eyessqueezed shut, furrowed nasolabial creases, open lips, pursed lips,stretched mouth, taut tongue, and a quivering chin.Adapted from Carlson, K. L., Clement, B. A., & Nash, P. (1996). Neonatal pain: From concept to re-search questions and the role of the advanced practice nurse. Journal of Perinatal Neonatal Nursing,10 (1), 64–71.

FIGURE 42–1THINKING CRITICALLY

DETERMINING WHEN A CHILD IS IN PAINFelicia, who is 5 years old, was struck by a car. Six hours ago, she hadsurgery to repair a liver laceration, but she also has numerous bruisesand abrasions on her body. After spending 3 hours in the postanes-thesia unit, she was moved to the pediatric inpatient unit. She has anintravenous line in place, as well as a nasogastric tube attached to lowsuction. Her abdominal dressing is clean and dry. Felicia has orders formorphine IV every 3 hours around the clock for the first 24 hours.

Felicia’s mother is rooming in with her during her hospital stay.Twelve hours after surgery, Felicia is dozing but is responsive to verbalstimuli. Her most recent IV morphine was given 2 hours ago.The nurseattempts to determine how well Felicia’s pain is managed. Her facialexpression indicates that she is not in pain. Felicia’s mother feels thatshe is resting fairly comfortably.

How do you know whether Felicia is in pain? Can you expect herto tell you if she feels pain? Is any additional assessment needed tojustify giving Felicia more pain medication? What other pain relief mea-sures could reduce or help to control her pain in the first 24 hours?

What is the appropriate dose of IV morphine for Felicia, whoweighs 25 kg? What is the timing of assessments of response to painand potential side effects? What signs of respiratory distress indicatea need for naloxone administration?

Responses to Pain Potential Physiologic Consequences

Respiratory ChangesRapid shallow breathing Alkalosis

Inadequate lung expansion Decreased oxygen saturation, atelectasis

Inadequate cough Retention of secretions

Neurologic ChangesIncreased sympathetic nervous system activity Tachycardia, change in sleep patterns, increased blood glucose and

cortisol levels

Metabolic ChangesIncreased metabolic rate with increased perspiration Increased fluid and electrolyte losses

Immune System ChangesDepression of immune response Increased risk of infection

Gastrointestinal ChangesIncreased intestinal secretions and smooth muscle sphincter tone Impaired gastrointestinal functioning, ileus

Data from Eland, J. M. (1990). Pain in children. Nursing Clinics of North America, 25, 871–884; Altimier, L., Norwood, S., Dick, M. J., et al. (1994). Postoperative pain management inpreverbal children: The prescription and administration of analgesia with and without caudal analgesia. Journal of Pediatric Nursing, 9(4), 226–232; McCaffrey, M., & Pasero, C.(1999). Pain: Clinical manual (2nd ed., p. 24, 27). St. Louis, MO: Mosby; and Mitchell, A., & Boss, B. J. (2002). Adverse effects of pain on the central nervous systems of newbornsand young children: A review of the literature. Journal of Neuroscience Nursing, 34(5), 228–236.

TABLE 42–2 Physiologic Consequences of Unrelieved Pain in Children

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1211

1212 CHAPTER 42

DEVELOPING CULTURALCOMPETENCE

TERMS THAT DESCRIBE PAIN INTENSITYThe terms pain, hurt, and ache have been found to describe painintensity across cultures. Pain is most intense, hurt is less severe, andache is least severe (Gaston-Johansson, Albert, Fagan et al., 1990).Similarly, pain and hurt mean greater pain than ache in school-agechildren and adolescents (LaFleur & Raway, 1999). The term tenderor tenderness may be confusing for some families in which English isa second language. Tender or tenderness is more commonly associ-ated with caring or romance or with meat rather than soreness orpain.

DEVELOPING CULTURALCOMPETENCE

EXPRESSION OF PAINSome ethnic groups, such as Asian,Anglo-Saxon–Germanic, and Irish,do not openly express pain. People of Italian and Jewish descent aremore likely to use both verbal and nonverbal methods to express painfreely. However, children have individualized responses, and youngerchildren have had less time to acquire culturally learned behaviors.

Older children may be able to give a history of painfulprocedures. When attempting to obtain information aboutthe child’s pain experiences and present level of pain, keepin mind that many children modify their pain descriptionsdepending on the type of questions asked and what theyexpect will happen as a result of their response. Examplesof questions to ask include the following:

■ What kinds of things caused hurt in the past and whatmade it feel better?

■ Does the child tell others about being in pain and whatdoes the child want others to do for the pain?

■ What does the child not want done when he or she ishurting? What would the child like the nurse to dofor the hurt?

■ Where is the hurt, and what does it feel like? Whatcould be causing the hurting?

CULTURAL INFLUENCES ON PAINChildren’s culture and social learning have a tremendousinfluence on their expression of pain. Cultural traditionsoften guide children about self-control, coping, and enlist-ing the assistance of others (Huether & Leo, 2002). Chil-dren learn directly and indirectly from their parents abouthow to respond to pain. By showing approval and disap-proval, parents teach their children how to behave when inpain. This instruction includes the following:

■ How much discomfort justifies a complaint

■ How to express the complaint

■ How and when to stop complaining

■ Whom to approach for pain relief

For example, boys in the United States are usually encour-aged to hide their pain by acting brave and not crying. Girlsare often encouraged to express their pain openly. Childrenalso observe other family members in pain and imitatetheir responses (Abu-Saad, 1984).

DEVELOPMENTAL RESPONSES TO PAINA child’s responses to and understanding of pain depend onthe child’s age and stage of development. See Tables 42–3and 42–4 to learn more about the child’s responses at eachage.A child’s responses to pain also depend upon situationalfactors that influence pain responses (McGrath, 1995):

■ Cognitive—understanding of the pain source, ability tocontrol what will happen, focus of attention is on thepain or a distraction

■ Behavioral—use of a pain control strategy, ability tocontinue usual activities, response of parents andhealthcare providers

■ Emotional—presence of fear, anxiety, frustration,anger, depression

Young children are unable to give a detailed description oftheir pain because of their limited vocabulary and painexperiences. Depending on their developmental stage, chil-dren use different coping strategies, such as escape, post-ponement or avoidance, diversion, and imagery, to dealwith pain. Healthcare providers now recognize that chil-dren do not complain of pain for several reasons:

■ Some children believe they need to be brave.

■ Preschoolers and adolescents may assume the nurseknows they have pain.

■ Some children are afraid that an injection to relievepain will hurt more than the pain they have.

GROWTH AND DEVELOPMENT

School-age children and adolescents may not exhibit distress in directproportion to their pain intensity. Thus, behavioral measures may notmatch the child’s self-report of pain intensity. Older children often ap-pear calm, are expressionless, and limit movement following surgery,but report pain of moderate to severe levels (Tesler et al., 1999). Be-cause children in these age groups can accurately report pain inten-sity, use the self-report of pain as a valid pain assessment.

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1212


Age Group Behavioral Response Verbal Description

Infants�6 months Generalized body movements, chin quivering, facial

grimacing, poor feeding

6–12 months Reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritability, restlessness

Toddlers1–3 years Localized withdrawal, resistance of entire body, aggressive

behavior, disturbed sleep

Preschoolers3–6 years Active physical resistance, directed aggressive behavior,(preoperational) strikes out physically and verbally when hurt, low

frustration level

School-Age Children7–9 years Passive resistance, clenches fists, holds body rigidly still,(concrete operations) suffers emotional withdrawal, engages in plea bargaining

10–12 years May pretend comfort to project bravery, may regress with (transitional) stress and anxiety

Adolescents13–18 years Want to behave in a socially acceptable manner (like (formal operations) adults), show a controlled behavioral response

TABLE 42–3 Behavioral Responses and Verbal Descriptions of Pain by Children of Different Developmental Stages

Cries

Cries

Cries and screams, cannot describe intensity or type ofpain

Can identify location and intensity of pain, denies pain,may believe his or her pain is obvious to others

Can specify location and intensity of pain and describeits physical characteristics in relation to body parts

Able to describe intensity and location with morecharacteristics, able to describe psychologic pain

More sophisticated descriptions as experience is gained;may think nurses are in tune with their thoughts, so theydon’t need to tell the nurse about their pain

PAIN ASSESSMENT SCALESVarious pain scales are used to assess pain in children.

Nonverbal ChildrenPhysical and behavioral indicators are used to quantify painin nonverbal children.For example, the Neonatal Infant PainScale (NIPS) and the FLACC Behavioral Pain AssessmentScale rely on the nurse’s observation of the child’s behavior.

The NIPS is designed to measure procedural pain inpreterm and full-term newborns up to 6 weeks after birth.The newborn facial expression, cry quality, breathing pat-terns, arm and leg position, and state of arousal are ob-served. This tool has high inter-rater reliability and validity.See Table 42–5 on p. 1215.

The FLACC is designed to measure acute pain in in-fants and young children following surgery, and it can beused until the child is able to self-report pain with anotherpain scale. FLACC is an acronym for the five categories thatare assessed: Face, Legs, Activity, Cry, and Consolability. Touse FLACC the nurse observes the child during routinecare for 1 to 5 minutes, and then selects the score that mostclosely matches each behavior noted. The scores for the fivecategories are added together for the total score. The toolhas validity and reliability for evaluation of postoperative

pain (Manworren & Hynan, 2003; Willis, Merkel, Voepel-Lewis, et al., 2003). See Table 42–6 on p. 1215.

Young children (3 years and older) can localize pain ifgiven an outline of the front and back of the body. Thechild can mark where the pain is located or color the areaof pain with crayons. The child should use one color for theplace where it hurts the most, and another color for areaswith less pain.

Self-Report Pain ScalesOther scales depend on the child’s self-report of pain in-tensity (see Skill 13–1). To use pain scales, the childmust be developmentally ready and understand the con-cept of a little or a lot of pain well enough to tell the nurse.Children 2 to 3 years of age are usually able to understandthe concept of “more or less.” This child cannot be givenmore than three choices on a pain scale (none, some, a lot)when assessing pain. When the child can understand rankorder and is able to classify, match, and estimate, a numericscale can be used. A child who correctly responds to eitherof the following items is developmentally ready for a nu-meric scale (Merkel, 2002):

■ Which number is larger, 5 or 9? Which number issmaller, 7 or 4?

SKILLS

MED

IALIN

KSkill 13-1: Selected Pediatric Pain Scales

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1213

1214 CHAPTER 42

Developmental Stage Understanding of Pain

Infants< 6 months No apparent understanding of pain; newborns exposed to repeated painful experiences in ICU demonstrate

memory of pain by holding their breath when approached by care providers

6–12 months Anticipate a painful event such as an immunization with fear; responsive to parental anxiety

Toddlers1–3 years Do not understand what causes pain and why they might have pain; demonstrate fear of painful situations; use

common words for pain such as owie and boo-boo

Preschoolers3–6 years Pain is a hurt; have language skills to express pain, and skills increase with age; do not relate pain to illness but(preoperational) may relate pain to an injury; often believe pain is punishment; do not understand why a painful procedure will

make them feel better or why an injection takes pain away

School-Age Children7–9 years Can understand simple relationships between pain and disease but have no clear understanding of the cause of (concrete operations) pain; can understand the need for painful procedures to monitor or treat disease; may associate pain with feeling

bad or angry; may recognize psychologic pain related to grief and hurt feelings

10–12 years Better able to understand the relationship between an event and pain; have a more complex awareness of (transitional) physical and psychologic pain, such as moral dilemmas and mental pain

Adolescents13–18 years Have a sophisticated understanding of the causes of physical and mental pain; relate to the pain experienced(formal operations) by others; pain has both qualitative and quantitative characteristics

TABLE 42–4 Children’s Understanding of Pain by Developmental Stage

■ Ask the child to place several blocks or pieces of paperof different sizes in a row from biggest to smallest.

Examples of self-report pain scales include the Faces PainScale and the Oucher Scale. The Oucher Scale presents a se-ries of six photographs of a child expressing increased inten-sity of pain in combination with a vertical Visual Analog Scale(Figure 42–2 on p. 1216). The child selects a face that bestfits his or her level of pain; an older child can select a numberbetween 0 and 10. The nurse should not compare the photoswith the child’s facial expression to determine pain level. Thetool has been developed for three cultural groups with valid-ity and reliability for children between 3 and 12 years of age.

The Faces Pain Rating Scale has a series of six cartoon-like faces with expressions from smiling to tearful that can beused by children starting at 3 years of age (Figure 42–3 ).The nurse explains the meaning of each face and asks thechild to select the face that is the closest match to the pain felt.As with the Oucher Scale, the nurse should not compare thefaces with the child’s facial expression to determine painlevel. Comparison of faces pain scales has revealed that thosescales with a smiling face as the indicator of no pain resultedin significantly higher pain ratings by children and parentsthan scales using a neutral expression face as an indicator ofno pain (Chambers, Gresbrecht, Craig et al., 1999).

School-age children and adolescents have better num-ber concepts and language skills, so additional tools can be

used to assess their pain. The nurse should ask the child todescribe the pain and give its location. At about 8 years ofage, children can give a separate rating for the intensity ofpain and describe how unpleasant it is (Jedlinksy, Mc-Carthy, & Michel, 1999). Providing some words such assharp, dull, aching, pounding, cold, hot, burning, throb-bing, stinging, tingling, or cutting can help children de-scribe their pain.

The Numeric Pain Scale or Visual Analog Scale is a sin-gle 10-cm horizontal or vertical line that has descriptors ofpain at each end (no pain, worst possible pain). Marks andnumbers are placed at each cm on the line.

The Poker Chip Tool uses four checkers or poker chipsto quantify pain. The child is asked to pick the number ofchips that best match the pain felt, with one chip being a lit-tle pain and four being the most pain he or she could have.

The Word-Graphic-Rating Scale has words describingincreasing pain intensity across a horizontal line. The childmarks the line that is closest to the level of pain felt. A mil-limeter ruler can be used to quantify the pain and recordthe pain score (Figure 42–4 on p. 1217).

The Adolescent Pediatric Pain Tool includes a humanfigure drawing, the Word-Graphic Rating Scale, and achoice of descriptive words. Adolescents indicate painsites on the human figure outline, use the Word-Graphic-Rating Scale as described, and use the word choices tocharacterize the pain felt.

MED

IALI

NK

Ouch

er S

cale

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1214


Characteristic Scoring Criteria Characteristic Scoring Criteria

Facial Expression0 � Relaxed muscles ■ Restful face with neutral expression1 � Grimace ■ Tight facial muscles; furrowed

brow, chin, and jaw (Note: At lowgestational ages, infants may haveno facial expression)

Cry0 � No cry ■ Quiet, not crying1 � Whimper ■ Mild moaning, intermittent cry2 � Vigorous cry ■ Loud screaming, rising, shrill, and

continuous (Note: silent cry may be scored if infant is intubated,as indicated by obvious facialmovements)

Breathing Patterns0 � Relaxed ■ Relaxed, usual breathing pattern 1 � Change in breathing maintained

■ Change in drawing breath;irregular, faster than usual,gagging, or holding breath

TABLE 42–5 Neonatal Infant Pain Scale (NIPS)

Used with permission from Lawrence, J., Alcock, D., McGrath, D. P., et al. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 61.

Arm Movements0 � Relaxed/restrained ■ Relaxed, no muscle rigidity,

(with soft restraints) random movements of arms1 � Flexed/extended ■ Tense, straight arms; rigid; or rapid

extension and flexion

Leg Movements0 � Relaxed/restrained ■ Relaxed, no muscle rigidity,

(with soft restraints) occasional random movements 1 � Flexed/extended of legs

■ Tense, straight legs; rigid; or rapidextension and flexion

State of Arousal0 � Sleeping/awake ■ Quiet, peaceful, sleeping; or alert 1 � Fussy and settled

■ Alert and restless or thrashing; fussy

SCORING

Categories 0 1 2

Face No particular expression or smile Occasional grimace or frown; Frequent to constant frown, clenched jaw,withdrawn, disinterested quivering chin

Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up

Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking

Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs; frequent complaints

Consolability Content, relaxed Reassured by occasional touching, hugging, Difficult to console or comfortor being talked to; distractable

Observe the child for 5 minutes or longer. Observe the legs and body uncovered. Reposition the patient or observe activity. Assess body for tenseness and tone. Initiate consolinginterventions if needed. Each of the five categories is scored from 0 to 2, resulting in a total score between 0 and 10. A total score of 0 � relaxed and comfortable; 1–3 � milddiscomfort; 4–6 � moderate pain; 7–10 � severe discomfort or pain.

Used with permission from Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring post-operative pain in young children.Pediatric Nursing, 23(3), 293–297.

TABLE 42–6 FLACC Behavioral Pain Assessment Scale

CLINICAL THERAPY FOR PAINPain management includes both drug and nondrug mea-sures. Children need adequate pain medication, but non-drug measures can enhance pain management andultimately reduce the amount of pain medication needed.

PAIN MEDICATIONSDrug interventions include the use of opioids, nonsteroid-al anti-inflammatory drugs (NSAIDs), and nonnarcoticanalgesics (acetaminophen).

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1215

1216 CHAPTER 42

Use the Oucher Scale that is the bestmatch for the ethnicity of the child. Af-ter determining that the child has anunderstanding of number concepts,teach the child to use the scale. Pointto each photo and explain that thebottom picture is “no hurt,” the secondpicture is a “little hurt,” the third pictureis “a little more hurt,” the fourth pictureis “even more hurt,” the fifth picture is“a lot of hurt,” and the sixth picture isthe “biggest or most hurt you couldever have.” The numbers beside thephotos can be used to score theamount of pain the child reports.The Caucasian version of the Oucher used with per-mission from Judith E. Beyer, RN, PhD, 1983. TheAfrican-American version of the Oucher used withpermission from Mary J. Denyes, RN, PhD, and An-tonia M. Villarruel, RN, PhD, 1990. The Hispanic ver-sion of the Oucher used with permission fromAntonia M. Villarruel, RN, PhD, 1990.

FIGURE 42–2

0 No Hurt

1 Hurts

Little Bit

2 Hurts

Little More

3 Hurts

Even More

4Hurts

Whole Lot

5HurtsWorst

The Faces Pain Rating Scale is valid and reliable in helping children to report their level of pain. Make sure the child has an understanding of numberconcepts 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 childfeels. Then ask the child to select the face that comes closest to the amount of pain felt.Used with permission from Wong, D. L., & Baker, C. M. (1988). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14, 9–16.

FIGURE 42–3

OpioidsOpioids are commonly given for severe pain, such as aftersurgery or a severe injury. Opioids (e.g., morphine andcodeine) may be administered by oral, subcutaneous, in-tramuscular, and intravenous routes. Administration of

opioids by an oral route is as effective as by intramuscularand intravenous routes when the drug is given in anequianalgesic dose (the amount of drug, whether givenby oral or parenteral routes, needed to produce the sameanalgesic effect) (Table 42–7). Oral and intravenous routes

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1216


NoPain

ModeratePain

WorstPossible

Pain

LittlePain

LargePain

Word-Graphic Rating Scale has words rather than numbers under the line.It may be used by itself or with the Adolescent Pediatric Pain tool. Teach thechild to use the tool by pointing to the side of the line that is no pain. Thenrun your finger along the line and tell the child that this location is the worstpossible pain. If the child has some pain, ask the child to make a markalong the line that is the best match for the amount of pain felt. Use a mil-limeter ruler to measure from the “no pain” end of the line to the markedlocation to identify the pain score. Make sure the line is the same lengtheach time pain is assessed so comparisons can be made.Used with permission from Sinkin-Feldman, L., Tesler, M., & Savedra, M. (1997). Word placement onthe Word-Graphic Rating Scale by pediatric patients. Pediatric Nursing, 23, 31–34.

FIGURE 42–4 are preferred for children. Rectal preparations of someopioids are also available. The optimal analgesic dosevaries widely among patients in all age groups (AmericanPain Society, 1999).

Common side effects include sedation, nausea, vomit-ing, constipation, and itching. Potential complications ofopioids include respiratory depression, cardiovascular col-lapse, and addiction. When the child’s condition is unsta-ble, as in trauma or critical illness, the dosage of opioidsmust be carefully calculated to match the child’s cardiores-piratory status, although infants and children are no morelikely than adults to develop respiratory depression follow-ing administration of a weight-specific dose of narcotics(Holder & Patt, 1995). Addiction is a rare complication inadults and children treated for painful conditions.

When giving opioids over an extended period of time,children may experience withdrawal, the physical signs andsymptoms that occur when a sedative or pain drug is stoppedsuddenly in a patient with physical dependence. An examplewould be a child in an intensive care setting who experienced

Approximate Approximate Recommended Starting Recommended StartingEquianalgesic Equianalgesic Dose (Adults �50 kg) Dose (Children & Adults �50 kg)

Drug Oral Dose Parenteral Dose Oral Parenteral Oral Parenteral

Morphine 30 mg 10 mg 15–30 mg 10 mg 0.3 mg/kg 0.1 mg/kgevery 3–4 hr every 3–4 hr every 3–4 hr every 3–4 hr

Codeine 130 mg 75 mg IM or 30–60 mg 60 mg 0.5–1 mgSubcutaneous every 3–4 hr every 2 hr every 3–4 hra NR

Hydromorphone 7.5 mg 1.5 mg 4–8 mg 1.5 mg 0.06 mg/kg 0.015 mg/kg(Dilaudid) every 3–4 hr every 3–4 hr every 3–4 hr every 3–4 hr

Levorphanol 4 mg (acute) 2 mg (acute) 2–4 mg 2 mg 0.04 mg/kg 0.02 mg/kg(Levo-Dromoran) 1 mg (chronic) 1 mg (chronic) every 6–8 hr every 6–8 hr every 6–8 hr every 6–8 hr

Meperidine 300 mg 100 mg NR 100 mg NR 0.05–1.5 mg/kg(Demerol) every 3 hr every 2–4 hr

Methadone 20 mg (acute) 10 mg (acute) 5–10 mg 10 mg 0.2 mg/kg 0.1 mg/kg (Dolophine, others) 2–4 mg (chronic) 2–4 mg (chronic) every 6–8 hr every 6–8 hr every 6–8 hr every 6–8 hr

Oxycodone 30 mg NA 5–10 mg NA 0.1–0.2 mg/kg NA(Roxicodone) every 3–4 hr every 3–4 hra

Fentanyl NA 0.01 mg 5 mcg/kg 50–100 mcg 5–15 mcg/kg 1 mcg/kgLozenge every 1–2 hr Oraletb

NR � Not recommended; NA � Not available

*For all parenteral opioids, start with the low dose and titrate to effective pain control.a Caution: Doses of aspirin and acetaminophen in combination with opioid/NSAID preparation must also be adjusted to the patient’s body weight.b The Oralet is not widely used because of nausea and vomiting side effects.

Data from American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and cancer pain (4th ed., pp. 6–8, 14–15, 20). Glenview, IL: Author; Hazinski,M. F. (1999). Analgesia, sedation, and neuromuscular blockade in pediatric critical care. In M. F. Hazinski, Manual of pediatric critical care (pp. 44–72). St. Louis, MO: Mosby; andAcute Pain Management Guideline Panel. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Quick reference guide forclinicians (AHCPR Pub. No. 92–0020). Rockville, MD: Agency for Healthcare Policy and Research, U.S. Public Health Service, Department of Health and Human Services.

TABLE 42–7 Opioid Analgesics and Recommended Doses for Children and Adolescents*

lon23944_ch42.qxd 2/17/06 8:53 AM Page 1217

1218 CHAPTER 42

System Signs and Symptoms

Central nervous Irritability, increased wakefulness,system tremulousness, hyperactive deep tendon

reflexes, clonus, inability to concentrate,frequent yawning, sneezing, delirium,hypertonicity, visual or auditory hallucinations

Gastrointestinal Feeding intolerance with vomiting, diarrhea,system uncoordinated suck and swallow

Sympathetic Tachycardia, tachypnea, increased bloodnervous system pressure, nasal stuffiness, sweating, fever

Data from Tobias, J. D. (2000). Tolerance, withdrawal, and physical dependency afterlong term sedation and analgesia of children in the pediatric intensive care unit.Critical Care Medicine, 28(6), 2122–2132. Adapted.

TABLE 42–8 Signs and Symptoms of Opioid or SedativeWithdrawal

life-threatening injuries, multiple surgeries, and invasive pro-cedures for long-term treatment.Slowly weaning the child offthe opioid over 2 to 4 weeks will prevent withdrawal symp-toms. See Table 42–8 for signs and symptoms of withdrawal.

Acetaminophen and Nonsteroidal Anti-inflammatory DrugsNSAIDs such as aspirin, primarily given orally, are effectivefor the relief of mild to moderate pain and chronic pain.Table 42–9 presents recommended dosages of these drugs.They are most commonly used for bone, inflammatory,

and connective tissue conditions. An NSAID may be pre-scribed in combination with an opioid to increase the ef-fectiveness of the narcotic drug, which may ultimatelyreduce the amount of opioids needed.

Acetaminophen is a nonnarcotic analgesic that is usedlike an NSAID. It works by raising the pain threshold andis equal to aspirin in analgesic properties.

DRUG ADMINISTRATIONPain from surgery, major trauma, or cancer is present forpredictable periods because of the effects of tissue damage.

NURSING PRACTICE

Respiratory depression (unresponsiveness and a respiratory rate lessthan 12 breaths/min in children less than 2 years of age) mayprogress to respiratory arrest and is the major life-threatening com-plication of opioid administration. Clinical signs that predict the de-velopment of respiratory depression include sleepiness, small pupils,and shallow breathing. Children at particular risk for respiratory de-pression induced by an opioid are those with an altered level of con-sciousness, an unstable circulatory status, a history of apnea, or aknown airway problem. Some hospitals use continuous pulse oxime-try when children at risk for respiratory depression receive opioids.

Respiratory depression is most likely to occur when the child issleeping. This augments the depressant effect on the respiratory cen-ter and potential airway obstruction by the tongue (American Pain So-ciety, 1999). Identify the time interval before drug-specific peakrespiratory depression occurs, and then carefully monitor the child’svital signs during that period to detect respiratory depression. Nalox-one is the drug used for reversal of opioids’ adverse effects.

Oral NSAID Peak Action Time Usual Adult Dose Usual Pediatric Dose Comments

Acetaminophen 0.5–2 hr 500–1000 mg every 4–6 hr 10–15 mg/kg every Lacks the peripheral anti-inflammatory 4–6 hr activity of other NSAIDs; rectal suppository

available

Aspirin 1–2 hr 650–975 mg every 4–6 hr 10–15 mg/kg every Do not use in children under 12 years with 4 hr possible viral illness; may cause gastric upset

and bleeding; rectal suppository available

Choline magnesium trisalicylate 1000–1500 mg every 12 hr 25 mg/kg every 12 hr Does not increase bleeding time like other (Trilisate) 2 hr NSAIDs; also available as oral liquid

Ibuprofen (Motrin, others) 0.5 hr 200–400 mg every 4–6 hr 10 mg/kg every 6–8 hr Available as oral suspension

Naproxen (Naprosyn) 2–4 hr 500 mg initial dose followed 5 mg/kg every 12 hr Available as oral liquidby 250 mg every 6–8 hr

Data from American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and cancer pain (4th ed., pp. 6–8, 14–15, 20). Glenview, IL: Author; Hazinski,M. F. (1999). Analgesia, sedation, and neuromuscular blockade in pediatric critical care. In M. F. Hazinski, Manual of pediatric critical care (pp. 44–72). St. Louis, MO: Mosby; andAcute Pain Management Guideline Panel. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Quick reference guide forclinicians (AHCPR Pub. No. 92-0020). Rockville, MD: Agency for Healthcare Policy and Research, U.S. Public Health Service, Department of Health and Human Services.

TABLE 42–9 Acetaminophen, NSAIDs and Recommended Doses for Children and Adolescents

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1218


ACETAMINOPHEN

DRUG GUIDE

Nursing Implications■ Assess: Note hepatic and renal function. Assess pain level or

actual temperature prior to administration.■ Administer: Follow dosage directions carefully for different liquid

preparations. Concentration differs between drops and elixir.Plain or chewable tablets may be crushed and given with fluid;avoid giving with high-carbohydrate meals, which can decreasedrug absorption.

■ Monitor: Evaluate the response to medication. Periodic renal andhepatic studies may be ordered for patients on long-term therapy.

■ Patient teaching: Do not give with other over-the-countermedications unless directed by healthcare provider as they mayalso contain acetaminophen or aspirin. Consult a physician fordosage in a child younger than 2 to 3 years, if fever or illnesspersists over 3 days, or if relief is not obtained. Limit child to 5doses/day. Store out of the child’s reach as this medication is afrequent cause of childhood poisoning.

Data from: Wilson, B.A., Shannon, M.T., & Stang, C. L. (2005). Prentice Hall nurse’sdrug guide. Upper Saddle River, NJ: Prentice Hall; Taketoma, C. K., Hodding, J. H., &Kraus, D. M. (2002). Pediatric dosage handbook (9th ed.). Hudson, OH: Lexi-Comp.

Overview of ActionProduces analgesia by unknown mechanism. Acts in the hypothala-mus to cause antipyresis. Used in treatment of mild to moderate painand of fever. Does not have anti-inflammatory effects. Does not affectbleeding time.

Routes, Dosage, FrequencyOral or rectal: 10 to 15 mg/kg/dose every 4 to 6 hours, as needed.Do not exceed 5 doses/day. If not prescribed by healthcare provider,seek medical advice after 5 doses for either fever or pain. Children 12years and older should not exceed 4 g per day.

Contraindications: Previous allergy to the drug and G6PD defi-ciency. Do not give preparations with aspartame to children withphenylketonuria. Use cautiously in children with hepatic dysfunction,anemia, renal dysfunction, or rheumatoid arthritis.

Drug interactions: Chronic coadministration with carbamaze-pine, phenytoin, barbiturates, and rifampin may increase potential forchronic hepatotoxicity.

Side effects: Liver damage with overdose.

Pain relief should be provided around the clock. Every ef-fort should be made to give the child analgesics withoutcausing more pain. The preferred routes of administrationare intravenous, local nerve block, and oral.

Continuous infusion analgesia is recommended forchildren with continuous or persistent severe pain becauseconstant drug levels eliminate peaks and valleys in paincontrol. Analgesics may also be given intravenously on ascheduled basis (e.g., every 3 to 4 hours). Delays in givinganalgesics increase the chances of breakthrough pain andthe subsequent anticipation of pain. Giving analgesics onan as-needed basis for acute pain also results in the loss ofpain control. More medications are often needed to restorepain control than would have been required for continuousinfusion analgesia.

Patient-Controlled AnalgesiaPatient-controlled analgesia (PCA) is a method of admin-istering an intravenous analgesic, such as morphine, usinga computerized pump programmed by the healthcare pro-fessional and controlled by the child (Skill 13–2). Acontinuous infusion of opioid prevents a recurrence ofpain during long sleeping periods. This method of painmanagement is especially useful for pain control in the first48 hours after surgery when oral pain management is notpossible. PCA is prescribed mostly for children 5 years ofage and older. Children selected for PCA should be able topush the injection button and understand that pushing the

SKILLS

button will give them medication to relieve pain. Parentsare sometimes given responsibility for pushing the injec-tion button for younger children or those with disabilities.

After initial pain control has been achieved with an IVinfusion by the nurse, the child presses a button to receivea smaller analgesic dose for episodic pain relief. Safety fea-tures that include the ability to set the maximum numberof infusions per hour and the maximum amount of drugreceived in a given time period prevent overdoses. Ad-ditional pain medication is often ordered as needed tosupplement the continuous and patient-administered in-fusion when pain control is not maintained.

Children and adolescents benefit from PCA by receiv-ing continuous pain control and having the ability to con-trol their comfort level with no trauma from injections.Once children can take oral analgesics, PCA is discontinued.

REGIONAL PAIN MANAGEMENTEpidural pain control provides selective analgesia and hasbecome more common for postoperative pain manage-ment. A catheter is inserted into either the lumbar or thecaudal space. Only minute doses of drugs are needed be-cause of the high concentration achieved at the opioidreceptors in the spinal cord’s dorsal horn (Pasero, 2003).

Local nerve blocks, such as a popliteal block for anes-thesia and analgesia of an extremity, are used more fre-quently for pain control after surgery. A subcutaneouscatheter is inserted into the local area for infusion of the

MED

IALIN

KSkill 13-2: Patient Controlled Analgesia

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1219

1220 CHAPTER 42

■ What is PCA? Analgesia means pain relief: you get to control theamount of medicine you receive by using the machine.

■ The machine gives the medicine by passing it through the tubethat is connected to your intravenous line. When you push thebutton, the machine pumps pain medicine into the intravenousline to make you feel better.

■ The machine limits the amount of medicine you can get to whatthe doctor orders. You can get any amount up to the maximumby pushing the button repeatedly. The push button will not letyou make a mistake if you drop it or roll on it.

■ Whenever you feel pain, hurt, or discomfort, push the button toget more medicine. You should be the only one to push thebutton.

■ No needles for pain shots are needed as long as the intravenousline is in place.

■ The PCA may not relieve all of your pain, but it should make youfeel comfortable. Let the nurse know if you think your PCA is notworking.

■ The PCA will be used until you can take pills or drink liquid painmedicine.

PATIENT-CONTROLLED ANALGESIA (PCA)

TEACHING HIGHLIGHTS

analgesia. Pain control is achieved without systemic side ef-fects from the medication. Tingling felt in the fingers ortoes of the affected extremity is the first sign that the nerveblock is receding.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISNurses have an ethical obligation to relieve a child’s suffer-ing not only because of the consequences of unrelievedpain but also because appropriate pain management mayhave benefits such as earlier mobilization, shortened hos-pital stays, and reduced costs. To provide effective nursingmanagement of children in pain, anticipate the presence ofpain and recognize the child’s right to pain control.

When assessing pain in children, keep the followingquestions in mind:

■ What is happening in tissues that might cause pain?Assume that children who have had surgery, injury,vaso-occlusive episode, or illness are experiencing pain,since these events also cause pain in adults.

■ What external factors could be causing pain? Forexample, is the cast too tight or is the child poorlypositioned in bed?

■ Are there any indicators of pain, either physiologicor behavioral?

■ How is the child responding emotionally?

■ How does the child or parent rate the pain?

Physiologic symptoms such as nausea, fatigue, dyspnea,bladder and bowel distention, and fever may influencethe intensity of pain felt by a child. Fear, anxiety, separa-tion from parents, anger, culture, age, or a previous painexperience may also affect the child’s behavior or re-sponses to pain stimuli.

When working with an infant or child, determinewhich pain scale is the most appropriate for the circum-stance and developmental stage. When using a self-reportpain assessment tool, use the same tool each time you assessfor pain or for the evaluation of pain management. Thismakes comparison of assessment results possible. Achronologic record of the child’s pain assessments must bedocumented along with actions taken to relieve pain, in ad-dition to the follow-up assessments to determine the effec-tiveness of those actions.

Remember that surgery and trauma can result in mul-tiple sites of pain (incision or laceration, cut or bruisedmuscles, interrupted blood supply, nasogastric tube place-ment, insertion sites of intravenous lines). When usingpain scales in the assessment of a verbal child, attempt toidentify all sites of pain. Then evaluate the intensity of painat each site.

Examples of nursing diagnoses for children in pain in-clude the following:

■ Acute Pain (abdominal) related to injury and surgery

■ Anxiety related to anticipation of pain from aninvasive procedure

■ Sleep Pattern Disturbed related to inadequate pain control

■ Ineffective Individual Therapeutic Regimen Managementrelated to self-management of pain control, and use ofnonpharmacologic pain-control measures

■ Ineffective Breathing Pattern: Potential for, related toopioid overdose

■ Risk for Constipation related to opioid pain medicationand limited activity

PLANNING AND IMPLEMENTATIONNursing management involves the following actions to in-crease and maintain patient comfort once the assessment iscompleted and nursing diagnoses are developed: pharma-cologic intervention; nonpharmacologic intervention;monitoring, evaluating, and documenting the effectivenessof pain-control measures to provide optimal comfort; andpatient education.

The accompanying “Nursing Care Plan” summarizesnursing care for the child with postoperative pain.

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1220


NURSING CARE PLAN

THE CHILD WITH POSTOPERATIVE PAIN

Intervention Rationale Expected Outcome

1. Nursing Diagnosis: Severe Abdominal Pain related to surgery and injury

■ Give analgesic by a pain-free method.

■ Have the child select a pain scale andrate the amount of pain perceived beforeand 30–60 minutes after analgesia isgiven to ensure pain relief.

■ Assess pain control each hour to ensurethat the child’s pain is relieved.

■ Reposition the child every 2 hr tomaintain good body alignment.

■ Provide therapeutic touch or massage.Encourage the parents to read a story orplay favorite music.

■ The child may deny pain to avoidanalgesia by painful route.

■ The child’s pain rating is the bestindicator of pain. Maintenance of paincontrol requires less analgesia thantreating each acute pain episode.

■ Frequent monitoring identifies inadequatepain control before it becomessignificant.

■ New positions decrease muscle crampingand skin pressure.

■ Complementary therapy reduces stressand enhances the analgesic action.

The child reports pain relief afteradministration of analgesia.

NIC Priority Intervention:

Pain management: Alleviation of pain or areduction in pain to a level of comfort that isacceptable to the patient

NOC Suggested Outcome:

Comfort level: Feelings of physical andpsychologic ease

Goal: The child will report relief (to a level acceptable to the child on a pain scale).

2. Nursing Diagnosis: Disturbed Sleep Pattern related to inadequate pain control


Sleep enhancement: Facilitation of regularsleep/awake cycles

■ Give analgesia by continuous infusion orevery 3–4 hr around the clock.

■ Pain breakthrough occurs even duringsleep and disturbs the healing effects ofsleep.


Sleep: Extent and pattern of sleep formental and physical rejuvenation

The child’s sleep is undisturbed by pain.Child sleeps for age-appropriate number ofhours per day.

Goal: The child will experience fewer disruptions of sleep by pain.

3. Nursing Diagnosis: Ineffective Individual Therapeutic Regimen Management related to self-management of pain control and use ofnondrug pain-control measures


Self-modification assistance:Reinforcement of self-directed changeinitiated by the patient to achieve personallyimportant goals

■ Teach the child how the PCA works andwhen to push the button.

■ Teach the family and the child how to useage-appropriate imagery, distraction,relaxation techniques, and othercomplementary therapy pain-controlmeasures.

■ The child must know that pushing thePCA button will keep pain under control.

■ Complementary therapy pain-controlmeasures reduce the amount ofanalgesia needed.


Treatment behavior pain control: Personalactions to palliate or eliminate pain

The child’s pain rating stays low.

The child and family independently usecomplementary therapies for pain control.

Goal: The child and family will effectively use patient-controlled analgesia (PCA) and complementary therapy pain-control measures.

■ Discuss appropriate pain control to useat home after discharge.

■ The family and child may be anxiousabout pain management at home.

The family understands pain-relief measuresfor use at home and knows where to call ifhelp is needed.

Goal: The child and family will use appropriate analgesia after discharge.

(continued)

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1221

1222 CHAPTER 42

NURSING CARE PLAN—continued

THE CHILD WITH POSTOPERATIVE PAIN

Intervention Rationale Expected Outcome

4. Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to opioid overdose


Respiratory monitoring: Collection andanalysis of patient data to ensure airwaypatency and adequate gas exchange


Vital signs status: Temperature, pulse,respirations, and blood pressure withinexpected range for the individual

Goal: The child will maintain adequate ventilations.

■ Verify that correct dose of opioidanalgesia is given for the child’s weight.

■ Monitor vital signs and depth ofinspirations before analgesic isadministered and at time of peak drugaction.

■ Calculate agonist dose ordered byphysician to be sure it will reverserespiratory depression, but not counteracteffect of analgesia.

■ Respiratory depression is a significantcomplication of opioid analgesia whentoo much analgesia is given.

■ Respiratory depression episode must notprogress to respiratory arrest. All opioidsact on brainstem center, which decreasesresponsiveness to CO2 tension.

■ Valuable time will be saved if agonist isneeded for episode of respiratorydepression. Complete reversal ofanalgesia will cause the child to havesignificant pain.

There is no episode of respiratory depressionassociated with analgesia.

5. Nursing Diagnosis: Constipation related to opioid administration and decreased motility of gastrointestinal tract


Constipation management: Prevention andalleviation of constipation

■ Palpate the abdomen, and assess bowelsounds and abdominal distention.

■ Request physician order for stimulatinglaxative and stool softener.

■ Provide fluids of choice to increase fluidintake when IV fluids are decreased.

■ Inform family and child that constipationis a side effect of pain medication.

■ Signs of constipation must be anticipatedand identified.

■ Opioids increase the transit time of fecesand interfere with bile enzymes neededfor evacuation.

■ Extra fluids will counteract opioid actionof increasing the absorption of water fromthe large intestine.

■ Parents can become partners inmanaging fluid intake and monitoringbowel movements.


Bowel elimination: Ability of gastrointestinaltract to form and evacuate stool effectively.

The child has bowel movements at leastevery 2 days while on opioid pain control.

Goal: The child will have minimal constipation.

NURSING PRACTICE

Naloxone may be used to treat respiratory depression caused by anopioid drug at a dose and slow infusion rate that does not reverse thepain-control effects of the narcotic.A continuous infusion or repeateddoses may be needed for severe overdoses.

Pharmacologic InterventionGive analgesics as ordered by the physician, ensuring that thedose is appropriate for the child’s weight. When administer-ing an opioid by intravenous infusion or PCA, monitor theflow rate and the site for infiltration. Monitor the child’s vi-tal signs for complications related to opioids, such as respi-ratory depression.Vital signs (heart rate and blood pressure)may not change in response to effective analgesia when in-fection, trauma, or other stressors keep them elevated. Checkfor the presence of other side effects of analgesics, such as se-dation, nausea, vomiting, itching, urinary retention, andconstipation. Make sure analgesic antagonists such as nalox-one are available should complications develop.

When a regional nerve block is used, the analgesic ef-fect does not recede for several hours after the catheter isremoved. Be careful when ambulating a child with a re-gional nerve block in an extremity. Protect the extremityfrom injury because the child has reduced feeling in the

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1222


limb. Monitor the child for tingling of fingers or toes, an in-dication that the analgesic effect is receding. Begin oralanalgesia to maintain pain control.

Oral NSAIDs are generally ordered for less severe painor chronic pain. These drugs may mask fever. Be alert to thepotential complication of gastrointestinal hemorrhage incritically ill children who have increased gastric acids as aphysiologic stress response to pain.

Assess the child for pain 15 to 30 minutes following in-travenous pain medication and 1 hour after oral pain med-ication to determine if adequate pain control was achieved.Evaluate the child’s level of pain frequently to identify anyincrease in pain intensity. Use information collected fromthe child and parent, as well as from an appropriate painscale. Dramatic reductions in pain should occur, althoughnot all pain may disappear. Be certain to record results ofpain-control measures to guide future nursing actions. Usea flowsheet to document assessments and medication ad-ministration during the postoperative period.

Many children sleep after receiving an analgesic. Thissleep is not a side effect of the drug or a sign of an overdose,but the result of pain relief. Pain interrupts sleep, and oncepain is relieved, the child can sleep comfortably. However,sleep does not always indicate pain control. A child in painmay fall asleep in exhaustion. Look for other symptoms ofpain, such as excess movement or moaning.

Become an advocate for children when the dose or typeof analgesic ordered is inadequate. Tolerance is a decreasein a drug’s effect over time or the need for increasingamounts of the drug to produce or maintain the same levelof pain relief or sedation effect. This may occur when chil-dren with severe pain have been taking opioids or sedativesfor several days. Breakthrough pain occurs, and an increasein dosage is needed to achieve the previous level of pain re-lief. Tolerance can be delayed with effective use of painscales to allow appropriate drug dosing, and often less anal-gesia is needed. Magnesium may also slow the develop-ment of tolerance (Tobias, 2000).

Before asking the physician to change the analgesia, re-view the child’s record for documentation that the pre-scribed drug has been given at the appropriate dose andfrequency and that the child’s pain relief is ineffective despitethe drug administration. After verifying the record, providethe physician with information about the characteristics ofthe child’s pain and ask that the medication be changed.

Nonpharmacologic InterventionComplementary therapies are the nonpharmacologicmethods of pain control that can be used with or withoutanalgesics. The gate control theory helps explain why com-plementary pain management techniques are effective inhelping to control pain. Stimulation of the larger A-delta

GIVING CHILDREN ADEQUATE PAIN MEDICATION

Clinical QuestionWhy does adequate management of children with acute pain continueto be a problem?

EvidenceIn several recent studies, researchers found that some children continueto be undermedicated for moderate and severe pain despite continuingefforts to promote effective pain management for children (Higgins, Tur-ley, Harr et al., 1999; Vincent, 2001; Vincent & Denyes, 2004). A studyby Vincent and Denyes in 2004 explored factors related to the actions67 nurses took to relieve children’s pain in actual clinical situations in achildren’s hospital. The 132 children were experiencing pain fromsurgery, burns, vaso-occlusive episodes, and trauma. Nurses studiedhad a moderately high level of knowledge and attitudes about relievingchildren’s pain. Behavioral manifestations of pain led more nurses to be-lieve a child’s self-report of pain. Nurses did tend to give more analge-sia to children reporting higher pain levels, meaning that the child’s painlevel is what triggered the nurses to administer analgesia.

ImplicationsSurprisingly, 26% of children reporting pain received no analgesia, andthe 51% of children with moderate to high levels of reported pain re-ceived markedly less than the recommended and ordered amounts of

analgesia. Pediatric nurses have an obligation to ask children to reporttheir pain levels and then to accept that this pain rating is accurate. Be-havioral cues that pain exists should not be necessary to evaluate painin children who can self-report pain. Crying and grimacing in pain arenot the only pain behaviors to look for. Pain behaviors vary among chil-dren. For example, children use play as a distraction to self-managepain, and they sleep after becoming fatigued from dealing with pain.Children are entitled to comfort and pain relief, so all information thatinforms the nurse that the child is experiencing pain should be used inmaking decisions to relieve pain.

Critical ThinkingWhat could be some reasons for undermedication of children bynurses? What is your role in improving the pain management of childrenin all settings?

ReferencesVincent, C. V., & Denyes, M. J. (2004). Relieving children’s pain: Nurses’ abilities and

analgesic practices. Journal of Pediatric Nursing, 19(1), 40–50.Vincent, C. V. (2001). Nurses’ analgesic practices with hospitalized children. Journal

of Child and Family Nursing, 4(2), 79–89.Higgins, S. S., Turley, K. M., Harr, J., & Turley, K. (1999). Prescription and administration

of around the clock analgesics in postoperative pediatric cardiovascular surgerypatients. Progress in Cardiovascular Nursing, 14(1), 19–24.

EVIDENCE-BASED NURSING

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1223

1224 CHAPTER 42

Parents are the single most powerful nonpharmacologic method ofpain relief available to children. A parent’s presence greatly reducesthe anxiety associated with pain and hospitalization (Broome, 2000).Children often feel more secure telling their parents about their painand anxiety.When parents are actively participating in the child’s careduring hospitalization, teach them about how complementary thera-pies can be used to enhance the child’s pain management. Help theparent select the age-appropriate complementary therapy for thechild:■ Infants: holding, cuddling, sucking a pacifier, massage■ Toddlers: massage, stories, bubbles, touch, holding and rocking,

music (Figure 42–5)■ Preschoolers: engaging in play, stories, music, imagining being a

superhero, watching television or a video■ School-age children: rhythmic breathing, muscle relaxation,

guided imagery, talking about pleasant experiences, playinggames, listening to radio, watching television or a video

■ Adolescents: rhythmic breathing, muscle relaxation, guidedimagery, having visitors, playing games, watching television,listening to radio or CD player

HELPING A CHILD COPE WITH PAIN

TEACHING HIGHLIGHTS

fibers by nonpainful touch and pressure such as massagecauses the substantia gelatinosa in the dorsal horn of thespinal cord to “close the gate” and decrease the transmis-sion of pain impulses to the brain (Franck, Greenberg, &Stevens, 2000; Huether & Leo, 2002). See “PathophysiologyIllustrated” on page 1209.”

One or more of these methods may provide adequaterelief of low levels of pain. When used with analgesics, non-pharmacologic techniques often increase the effectivenessof the analgesic or reduce the dosage required. When usedin association with a medical procedure, remember to usean intervention before, during, and after the procedure.This gives the child a chance to recover, feel mastery, andremember coping (Fanurik, Koh, Schitz et al., 1997).

Assemble a pain management kit to promote distrac-tion, imagery, and relaxation in children. Items that might beincluded are magic wands, pinwheels, bubble liquid, a slinkyspring toy, a foam ball, party noisemakers, and pop-upbooks. It may also be helpful to include items for therapeu-tic play such as syringes, adhesive bandages, alcohol swabs,and other supplies from a medical kit.The pain managementkit may be especially helpful for distracting children who arebeing prepared for surgery or for painful procedures.Distraction. Distraction involves engaging a child in a widevariety of activities to help him or her focus attention onsomething other than pain and the anxiety associated withthe procedure. Examples of distracting activities are listen-ing to music, singing a song, playing a game, watching tele-

vision or a video, and focusing on a picture while counting.Select activities that are developmentally appropriate forthe child. Children in severe pain cannot be distracted, butdo not assume the pain is gone if a child can be distracted.Cutaneous Stimulation. Cutaneous stimulation involves gen-tly rubbing the painful area, massaging the skin gently, andholding or rocking the child. Touching provides a stimulusto compete with the pain stimuli transmitted from the pe-ripheral nerves to the spinal cord. These actions may re-duce the pain felt by the child. Swaddling and blanket rollsmay calm a distressed newborn by decreasing tactile stim-ulation and containing gross motor behaviors (Lynn,Ulma, & Spreker, 1999).Sucrose Solution. Concentrated sucrose solutions (12% or24%) with a pacifier may be used as a pain relief measurein newborns. Sucrose may provide a natural pain relief byactivating endogenous opioid systems in the body. Theanalgesic effect of sucrose lasts approximately 3 to 5 min-utes, with a peak action in 2 minutes (Mitchell & Waltman,2003). A moistened pacifier dipped in a packet of sugargiven to the infant during a painful procedure reduced painbehaviors such as duration of crying and vagal tone duringa heel stick (Greenberg, 2002).

FIGURE 42–5

The presence of the parent is an important part of pain management. Chil-dren often feel more secure telling their parents about their pain and anxiety.

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1224


HYPNOTHERAPY FOR CHILDRENThe most widely studied of the complementary/alternative therapies,hypnotherapy is often successfully prescribed as the primary treat-ment for a variety of childhood problems, including pain, bed-wetting,asthma, stool-withholding, habit disorders, anxiety and fears, migraineheadaches, nausea from chemotherapy, needle phobias, warts, in-somnia, tics, and other problems (Anbar, 2003; Thompson, 2004).

Children have a great capacity to use their imaginations and fan-tasy worlds for therapeutic gain and are actually more successful thanadults in attaining a hypnotic state. Children entering a healthcare en-vironment are often fearful. As the nurse, you can induce a more re-laxed state in children by speaking quietly, focusing them on theirbreathing, and suggesting they imagine something pleasant—the in-gredients of hypnotic induction.

Hypnosis is an altered state of awareness facilitating heightenedconcentration, decreased awareness of external stimuli, increased re-laxation, and increased suggestibility. Hypnotherapy can be as simpleas teaching a child to blow on a pinwheel while getting an injection.This diminishes the pain and fear of the needle by focusing the child’sheightened attention elsewhere. More formal hypnotherapy is done bya therapist trained in pediatric hypnotherapeutic techniques that usethe images and language of the child to induce relaxation and giveposthypnotic suggestions. Language such as, “You are the boss ofyour body and can help make this headache not bother you anymore”is used to help children gain mastery over their physical symptoms.

COMPLEMENTARY CAREElectroanalgesia. Also known as transcutaneous electricalnerve stimulation (TENS), electroanalgesia delivers smallamounts of electrical stimulation to the skin by electrodes.This electrical stimulation is stronger than the pain im-pulses, and because of the gate control theory, is thought tointerfere with the transmission of pain from the peripheralnerves to the spinal cord. TENS may be used for both acuteand chronic pain management. The only known side effectis skin irritation at the electrode site.Guided Imagery. Imagery is a cognitive process that encour-ages the child to focus concentration on an event or placeunrelated to the pain process. The focus can be on explor-ing a favorite place, doing a favorite activity, rememberinga funny story, or being a superhero. This method is most ef-fective in children over 6 years of age. Ask the child to thinkabout all the sights, sounds, smells, tastes, and feelings thatwill help him or her to experience the favorite place, activ-ity, or story. Guided imagery is a form of self-hypnosis, andit is most effective when preceded by a relaxation exercise.Relaxation Techniques. Relaxation techniques are used to re-duce muscle tension, which aggravates pain. Relaxationmethods include rhythmic breathing and alternately tens-ing and relaxing selected muscle groups for 10 secondseach. Progressively move from specific muscle groups tomore central muscles. Enhance relaxation by focusing thechild’s attention on something pleasant.Hypnosis. An altered state of consciousness occurs whenappropriate suggestions distort perception, memory, andmood. Children who respond to hypnotic suggestions areoften more relaxed and experience less pain. The precisephysiologic mechanism for the success of hypnosis in paincontrol is not known; however, the gate control theory maybe a factor.Application of Heat and Cold. Heat application promotes dila-tion of blood vessels. The increased blood circulation per-mits the removal of debris of cell breakdown from the site.Heat also promotes muscle relaxation, breaking thepain–spasm–pain cycle. To reduce edema, do not applyheat in the first 24 hours after an injury.

The application of cold is believed to slow the ability ofpain fibers to transmit pain impulses. Cold also controlspain by decreasing edema and inflammation and by caus-ing partial or complete anesthesia or numbness of the skin.When cold is applied, assess the skin for redness or signs ofirritation. Take care to avoid causing thermal injury. Dis-continue cold applications immediately if the skin alter-nately blanches and reddens afterwards or if blisters orredness do not subside between applications.

Discharge Planning and Home Care TeachingChildren are frequently discharged from the hospital withoral analgesics following surgery, injury, or treatment ofacute medical conditions. Parents have the responsibility

to provide adequate pain control for their child after daysurgery. The child usually leaves the surgical center pain-free, and the parents may not anticipate pain. Take thetime to discuss the importance of pain management andits benefits in promoting the child’s healing. Make sureparents know that a sudden increase in pain intensity in-dicates the development of a complication requiring med-ical attention.

Provide guidance to help parents assess their child’spain, and for school-age children and adolescents to assesstheir own pain. Teach parents and children about thedosage and frequency of administration and the side effectsof the analgesic ordered. Review nonpharmacologic meth-ods of pain control with parents and children. Encouragechildren and parents to use the techniques that work bestfor them.

Remember that many common health problems (oti-tis media, pharyngitis, and urinary tract infection) havepain as one of the presenting symptoms. Often the onlymedication prescribed is an antibiotic to clear the infec-tion. This may leave the child in pain for 48 to 72 hoursuntil the antibiotic brings the infection under control.Give parents recommendations for pain control and com-fort measures during this period. Review the dose, dosing

MED

IALIN

KHypnotherapy for Children

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1225

1226 CHAPTER 42

device, and formulation of acetaminophen used by par-ents to identify any risk for overdose.

EVALUATIONExpected outcomes of nursing care include the following:

■ The child’s pain level is assessed frequently and painmanagement is effective in improving the child’s comfort.

■ The child successfully uses a PCA pump to controlacute pain.

■ Age-appropriate nonpharmacologic methods of painmanagement enhance the comfort provided bymedications.

NURSING MANAGEMENT OF CHRONIC PAINSome children have medical conditions that cause chronicpain and episodic acute pain, such as rheumatoid arthritis,cancer, headaches, recurrent abdominal pain, and HIV in-fection. Chronic pain does not arouse the sympathetic ner-vous system in the same way that acute pain does. Thereforethe child may perceive pain but not appear to be in pain.

Physical and psychologic signs and symptoms shouldbe viewed together. No tools have been developed to assesschronic pain for any child age group. Assessment and eval-uation of chronic pain in children should include the fol-lowing aspects (American Pain Society, 2003):

■ Approach pain as the present problem and obtain thehistory of pain onset, its development over time,intensity, duration, location, what makes it worse orrelieves it, and its impact on daily life (sleeping,appetite, school, and social interactions).

■ Determine the amount of distress the child and familyexperience with pain, including anxiety, depression,and hopelessness.

■ Clarify what the family and child believe causes thepain and their response to it.

■ Identify past pain problems in the family and thecurrent methods of treatment.

■ Observe the child’s appearance, posture, gait, andemotional and cognitive state.

■ Assess muscle spasms, trigger points, areas sensitive tolight touch, and a complete neurologic examination.

Older children with recurrent episodes of pain can be en-couraged to keep a diary or log to describe the character-istics, timing, activities, and potential triggers of theirpain, as well as their response to pain treatment mea-sures. A pain assessment scale should be used to rate thepain intensity before and after medications and other

pain-control measures are used. This record can help im-prove pain management.

Examples of nursing diagnoses for children withchronic pain include the following:

■ Chronic Pain related to arthritic joint inflammationand degeneration

■ Disturbed Sleep Pattern related to ineffectivemanagement of chronic pain

■ Impaired Physical Mobility related to ineffectivemanagement of chronic pain

Children with chronic conditions (arthritis, sickle cell dis-ease, hemophilia, cancer, recurrent headaches, etc.) oftenneed long-term pain management. NSAIDs and aceta-minophen are often ordered for pain management. Strate-gies for chronic pain management include the following:

■ Explain and validate pain and its causes.

■ Encourage the use of a pain diary.

■ Discuss treatment goals with the child and family andjointly develop a care plan that integratespharmacologic and nonpharmacologic(complementary) methods.

■ Develop a care plan for sudden painful episodesassociated with acute flare-ups of their condition.

■ Provide effective preventive pain management forprocedural pain, as many of these children havenumerous medical procedures.

Parents should be actively engaged in pain control for theirchild. Teach parents the importance of pain control andhow to use a variety of complementary therapies with theirchild to supplement the pain medications administered.Refer children with long-term pain to a pediatric pain pro-gram to be evaluated for customized strategies to managepain.

SEDATION AND PAIN MANAGEMENT FOR MEDICAL PROCEDURESChildren undergo a wide variety of painful diagnostic andtreatment procedures in the hospital and in outpatient set-tings. Procedures such as chest tube insertion, arterialpuncture, lumbar puncture, bone marrow aspiration, frac-ture reduction, laceration repair, insertion of a central orperipheral intravenous line, and burn debridement causesignificant pain in children. The anticipation of these pro-cedures causes anxiety and emotional distress that can leadto greater intensity of pain. Children who have experiencedsevere pain in the past may be unwilling to cooperate withhealthcare personnel.

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1226


When painful procedures are planned, use EMLA cream to anesthetize theskin where the painful stick will be made. A, Apply a thick layer of creamover intact skin (one half of a 5-g tube). B, Cover the cream with a trans-parent adhesive dressing, sealing all the sides. The cream anesthetizes thedermal surface in 45 to 60 minutes.

FIGURE 42–6

A

B

NURSING PRACTICE

Whenever sedation is given, be sure to have the resources availableto monitor the child’s vital signs and to provide advanced life supportif the child should progress to deep sedation. In case complicationsoccur, the following equipment should be immediately available: suc-tion apparatus, a bag-valve mask for assisted ventilation with capa-bility of 90% to 100% oxygen delivery, and an oxygen supply (5 L/minfor more than 60 minutes). Antagonists to sedative medication mustbe premeasured and ready to administer.

CLINICAL THERAPY

Minor Medical ProceduresTopical anesthetics can be used to reduce the pain associatedwith the first needle stick.Vapocoolant sprays can be used forinjections. Eutectic mixture of local anesthetics (EMLA)cream,a mixture of 2.5% lidocaine and 2.5% prilocaine in anemulsion, is effective if applied 60 minutes before a needlestick procedure on intact skin (Rogers & Ostrow, 2004). SeeFigure 42–6 . A new preparation (ELA-MAX, 4% liposo-mal lidocaine) is effective if applied 30 minutes before a nee-dle stick (Eichenfield, Funk, Fallon-Friedlander et al., 2002).

A local anesthetic such as lidocaine buffered by sodiumbicarbonate is often injected to provide analgesia for emer-gency invasive procedures. Lidocaine can also be injectedsubcutaneously in a small area to reduce the pain of deeperneedle insertion.

SedationSedation is a medically controlled state of depressed con-sciousness (light to deep) used for painful diagnostic andtherapeutic procedures. Procedures such as burn debride-ment, laceration repair, bone marrow aspiration, and frac-ture reduction are associated with so much pain and anxiety

that children need premedication with analgesia andanxiolysis, mild sedation. Sedation is often used to gain thecooperation of the child for the medical procedure. Drugsfor sedation include the following (Proudfoot, 2002):

■ Benzodiazepines: diazepam (Valium), midazolam(Versed), and lorazepam (Ativan)

■ Hypnotics or barbiturates: thiopental, pentobarbital

■ Ketamine

■ Propofol (Diprivan)

■ Analgesics: Fentanyl, Alfentanil

When sedatives are given in lower doses, light sedation oc-curs during which the child maintains protective reflexes,maintains a patent airway, and appropriately responds toverbal stimuli. Deep sedation is a controlled state of de-pressed consciousness or unconsciousness in which theprotective reflexes are lost. See Table 42–10. Analgesia mustbe given in association with sedation because the sedatedchild can still feel pain but not communicate its presence.

Guidelines should exist in every healthcare facilitywhere pediatric sedation is performed to ensure safe health-care practices. These guidelines often require that the healthprofessionals monitoring the child have specific qualifica-tions, such as pediatric advanced life support training. Withthe combined effects of analgesia and sedatives, the childmust be carefully monitored for respiratory depression andsigns of deep sedation. Antagonist agents are available foropioids and benzodiazepines when the effects of sedationand respiratory depression need to be reversed. (See Skills13–3 and 13–4 for more information. )

NURSING MANAGEMENT

Increase Comfort During Painful ProceduresHelp the child cope with a painful procedure by telling thechild what sensations to expect and what will happen dur-ing the procedure. This reduces stress more effectively thanjust providing information about the procedure. SeeChapter 39 for methods of preparing children of differentdevelopmental ages for procedures.

SKILLS

MED

IALIN

KSkills 13-3 and 13-4

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1227

1228 CHAPTER 42

Assessment Factors Light Sedation Deep Sedation

Airway Able to maintain airway independently and continuously Unable to maintain airway independently or continuously

Cough and gag reflexes Reflexes intact Partial or complete loss of reflexes

Level of consciousness Easily aroused with verbal or gentle physical stimulation Not easily aroused, may not respond purposefully toverbal or gentle physical stimulation

Data from Proudfoot, J. (2002). Pediatric procedural sedation and analgesia (PSA): Keeping it simple and safe. Pediatric Emergency Medicine Reports, 7(2), 1–2.

TABLE 42–10 Characteristics of Light and Deep Sedation

Drug therapy is not always used for quick procedures,such as a dressing change, or an unexpected intravenousinsertion, injection, or venipuncture. Complementarytherapies, especially guided imagery, relaxation techniques,and distraction, may reduce the anxiety associated with theanticipation of the procedure. Teach parents and childrento use these interventions before procedures. Help childrencontrol their anxiety through therapeutic play.

When pharmacologic pain management is used for aprocedure, the nurse’s responsibilities include the following:

■ Treat anticipated procedure-related painprophylactically. For example, give an analgesic beforea bone marrow aspiration or fracture reduction.Permit time for the drug to become effective.

■ Manage preexisting pain before beginning a proceduresuch as scrubbing a burn.

■ Whenever possible, administer drugs by a nonpainfulroute (oral, transmucosal, intravenous). Avoidintramuscular or subcutaneous injections.

■ When procedures must be repeated (for example, bonemarrow aspirations for children with leukemia), giveoptimal analgesia for the first procedure to reduceanxiety about future procedures.

■ To prevent increased anxiety, avoid delays inperforming procedures.

■ Document the results of pain management.

When the child receives sedation, monitoring the child’s sta-tus is important. Nursing assessments include visual confir-mation of respiratory effort, color, and vital signs. Pulseoximetry and other technology may be used for monitor-ing, but the equipment must not replace visual assessment.Vital signs must be checked every 15 minutes until the childregains full consciousness and level of functioning. If lightsedation progresses to deep sedation, airway management isessential; check vital signs every 5 minutes.

Criteria for discharge after sedation include the fol-lowing (Bindler & Ball, 2003):

■ Satisfactory and stable cardiovascular function andairway patency.

■ Easily arousable, protective reflexes intact.

■ Adequate hydration.

■ Infant is able to hold the head up and sit up unassistedif old enough to do so, or the child can stand and walkwithout assistance.

■ Discharge status is the same as admission status.

Critical Concept ReviewLEARNING OBJECTIVES CONCEPTS

Describe the physiologic and behavioralconsequences of pain in children.

1. Physiologic consequences of acute pain:■ Tachycardia and rapid shallow breathing.■ Inadequate cough.■ Inadequate lung expansion.■ Depressed immune response.■ Increased perspiration and loss of electrolytes and fluids.■ Increased intestinal secretions.

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1228


LEARNING OBJECTIVES CONCEPTS

Select an appropriate tool to assess thepain of infants and children in each agegroup.

1. Infants and nonverbal children:■ Neonatal infant pain scale.■ FLACC Behavioral Pain Assessment Scale.

2. Young children:■ Color area of pain on outline of body.■ Faces pain scale.■ Oucher scale.

3. Older children and adolescents:■ Visual analog scale.■ Poker chip scale.■ Word graphic scale.■ Adolescent pediatric pain tool.

Describe the nursing assessment andmanagement for a child receiving an opioidanalgesic.

1. Use oral and intravenous route, if possible.2. Titrate dose to match child’s cardiorespiratory status.3. Identify line of peak drug effect and monitor child’s vital signs to detect respiratory depression.4. Observe for nausea, constipation and itching.5. Have nalaxone (Narcan) available for treatment of respiratory distress.

Explain the rationale for the effectiveness fornonpharmacologic (complementary)methods of pain control.

Nonpharmacologic methods of pain control are effective in children due to the Gate Control Theory.The use of methods such as nonpainful touch and massage stimulate the larger A-delta fibers anddecrease the transmission of pain impulses to the brain.

Assess children of different ages with acutepain and develop a nursing care plan thatintegrates pharmacologic interventions anddevelopmentally appropriatenonpharmacologic (complementary)therapies.

Interventions common to all ages:1. Assess pain frequently.2. Anticipate need for pain medication.3. Monitor vital signs.

Pharmacologic and nonpharmacologic interventions by age group:1. Infants and toddlers:

■ Administer oral or intravenous medications around the clock.■ Hold, swaddle, rock, or provide nonnutritive sucking.■ Allow infant to suck sucrose solution.■ Have toddler blow bubbles.

2. Preschooler:■ Use distraction techniques with the use of a magic wand, pinwheel, or noise maker.■ Allow child to watch appropriate TV shows or videos.

3. School-age child and adolescent:■ Instruct in use of PCA or epidural until able to take oral medications.■ Use hypnotherapy if child is able to cooperate.■ Engage child in breathing techniques for relaxation.■ Use guided imagery, visitors, TV, radio, tapes, or CDs for distraction.

Develop a nursing care plan for assessingand monitoring the child having sedationand analgesia for a medical procedure.

1. Explain procedure to the child and parents.2. Administer medications by oral or intravenous route, if possible.3. Employ nonpharmacologic methods such as distraction and guided imagery to decrease

anxiety.4. Use pulse oximetry and a cardiorespiratory monitor during procedure.5. After procedure is completed, check vital signs and level of consciousness frequently until child

is stable and awake.

2. Behavioral consequences of acute pain:■ Short attention span.■ Irritability.■ Facial grimacing.■ Posturing, protecting painful area, immobility.■ Lethargy or withdrawal.■ Sleep disturbance.

Describe the physiologic and behavioralconsequences of pain in children.—continued

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1229

1230 CHAPTER 42

MEDIALINK www.prenhall.com/london

■ NCLEX-RN® Review, case studies, and otherinteractive resources for this chapter can befound on the Companion Website athttp://www.prenhall.com/london. Click on“Chapter 42” and select the activities for thischapter.

■ For animations, more NCLEX-RN® Reviewquestions, and an audio glossary, access theaccompanying CD-ROM in this textbook.

REFERENCES

Abu-Saad, H. (1984). Cultural components ofpain: The Asian-American child. Children’s HealthCare, 13, 11–14.

American Pain Society. (1999). Principles ofanalgesic use in the treatment of acute pain and can-cer pain (4th ed.). Glenview, IL: Author.

American Pain Society. (2003). Pediatric chronicpain: A position statement from the American PainSociety. Retrieved October 22, 2003 from www.ampainsoc.org/cgi-bin/print/print/pl.

Anbar, R. (2001). Self-hypnosis for manage-ment of chronic dyspnea in pediatric patients.Pediatrics, 2, 21.

Anbar, R. D. (2003). Self-hypnosis for anxietyassociated with severe asthma: A case report. BMCPediatrics, 3(1), 3–7.

Bindler, R. C., & Ball, J. W. (2003). Clinical skillsmanual for pediatric nursing: Caring for children.(3rd ed.). Upper Saddle River, NJ: Prentice Hall.

Broome, M. E. (2000). Helping parents supporttheir child in pain. Pediatric Nursing, 26(3), 315–317.

Chambers, C. T., Gresbrecht, K., Craig, K. D.,Bennett, S. M., & Huntsman, E. (1999). A compar-ison of faces scales for the measurement of pedi-atric pain: Children’s and parent’s ratings. Pain,83, 25–35.

Eichenfield, L. F., Funk, A., Fallon-Friedlander, S.,& Cunningham, B. B. (2002). A clinical study to eval-uate ELA-MAX (4% liposomal lidocaine) as com-pared with eutectic mixture of local anesthetics creamfor pain reduction of venipuncture in children.Pediatrics, 109(5), 1093–1099.

Fanurik, D., Koh, J., Schitz, M., & Brown, R.(1997). Pharmacobehavioral intervention:Integrating pharmacologic and behavioral tech-niques for pediatric procedures. Children’s HealthCare, 26(1), 1–13.

Franck, L. S., Greenberg, C. S., & Stevens, B.(2000). Pain assessment in infants and children.Pediatric Clinics of North America, 47(3), 487–512.

Fuller, B. F. (2001). Infant behaviors as indica-tors of established pain. Journal of Society ofPediatric Nurses, 6(3), 109–115.

Gaston-Johansson, F., Albert, M., Fagan, E., &Zimmerman, L. (1990). Similarities in pain descrip-tions of four different ethnic-culture groups.Journal of Pain and Symptom Management, 5(2),94–100.

CRITICAL THINKING IN ACTION

View the Critical Thinking in Action video in Chapter 42 of the CD-ROM. Then, answer the questions that follow.

A 12-year-old boy, Kevin, isrecovering from a 4-wheeleraccident on the medicalsurgical unit at a localchildren’s hospital. He wasriding the 4-wheelerunsupervised and withoutpermission while his parentswere at work. He suffered anabdominal injury requiringsurgery, three broken bones

and several lacerations that needed stitches. His parents are very worriedabout his injuries and at the same time angry with him for not followingthe rules. Kevin appears expressionless in his hospital bed, but cries andgrimaces at any slight movement. When asked on a scale of 1–10 (10 being the most pain) how much pain he is feeling, he says a 10. Hisparents are reluctant to let him have any pain medications because theyfear he may become dependent on the medication. His father states that

Kevin should be a man and tolerate the pain, and he thinks enduring thepain will teach him a lesson about responsibility. The nurse explains thatpain management is necessary to improve Kevin’s healing, help himmobilize sooner, and potentially shorten his hospital stay. She explainsthe physiological consequences of ineffective pain management anddiscusses how the medication will help him sleep and rest. She explainsthat some of pain medications can be addicting, but the chances ofKevin becoming addicted to pain medications for this injury areextremely rare. She also reviews the nonpharmacological methods ofrelieving pain. The parents are still reluctant to the medications, but agreeto conform to the doctor’s orders.

1. What are some of the potential physiological consequences toletting Kevin suffer pain?

2. What are some examples of opioid analgesics available to Kevin?3. What are some examples of NSAIDs available to Kevin?4. What are the signs and symptoms of opioid withdrawal and how

long should it take for Kevin to be weaned off an opioid?

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1230


Greenberg, C. S. (2002). A sugar-coated pacifierreduces procedural pain in newborns. PediatricNursing, 22(3), 271–277.

Hazinski, M. F. (1999). Analgesia, sedation, andneuromuscular blockage in pediatric critical care.In M. F. Hazinski, Manual of pediatric critical care(pp. 44–72). St. Louis, MO: Mosby.

Higgins, S. S., Turley, K. M., Harr, J. & Turley, K.(1999). Prescription and administration of aroundthe clock analgesics in postoperative pediatric car-diovascular surgery patients. Progress inCardiovascular Nursing, 14(1), 19–24.

Holder, K. A., & Patt, R. B. (1995). Taming thepain monster: Pediatric postoperative pain manage-ment. Pediatric Annals, 24(3), 164–168.

Huether, S. E., & Leo, J. (2002). Pain, tempera-ture regulation, sleep, and sensory function. InK. L. McCance & S. E. Huether (Eds.),Pathophysiology: The biologic basis for disease inadults and children (4th ed., pp. 401–410). St. Louis,MO: Mosby–Year Book.

Jedlinksy, B. P., McCarthy, C. F., & Michel, T. H.(1999). Validating pediatric pain measurement:Sensory and affective components. PediatricPhysical Therapy, 11, 368–374.

Joint Commission on Accreditation ofHealthcare Organizations. (2001). Pain standardsfor 2001. Oakbrook Terrace, IL: Author.

LaFleur, C. J., & Raway, B. (1999). School-agechild and adolescent perception of the pain inten-sity associated with three word descriptors.Pediatric Nursing, 25(1), 45–55.

Lynn, A. M., Ulma, G. A., & Spreker, M. (1999).Pain control in very young infants: An update.Contemporary Pediatrics, 16(11), 39–66.

Manworren, R. C. B., & Hynan, L. S. (2003).Clinical validation of FLACC: Preverbal patientpain scale. Pediatric Nursing, 29(2), 140–146.

McCaffrey, M., & Pasero, C. (1999). Pain:Clinical manual (2nd ed.). St. Louis, MO: Mosby.

McGrath, P. A. (1995). Pain in the pediatric pa-tient: Practical aspects of assessment. PediatricAnnals, 24(3), 126–138.

McGrath, P. J., & Craig, K. D. (1989).Developmental and psychological factors in chil-dren’s pain. Pediatric Clinics of North America,36(4), 823–836.

Merkel, S. (2002). Pain assessment in infantsand children: The finger span scale. AmericanJournal of Nursing, 102(11), 55–56.

Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., &Malviya, S. (1997). The FLACC: A behavioral scalefor scoring post-operative pain in young children.Pediatric Nursing, 23(3), 293–297.

Mitchell, A., & Waltman, P. A. (2003). Oral su-crose and pain relief in preterm infants. PainManagement Nursing, 4(2), 62–69.

Pasero, C. (2002). Pain assessment in infantsand young children: Neonates. American Journal ofNursing, 102(8), 61–65.

Pasero, C. (2003). Epidural analgesia for post-operative pain. American Journal of Nursing,103(10), 62–64.

Proudfoot, J. (2002). Pediatric procedural seda-tion and analgesia (PSA): Keeping it simple and safe.Pediatric Emergency Medicine Reports, 7(2), 1–2.

Rogers, T. L., & Ostrow, C. L. (2004). The use ofEMLA cream to decrease venipuncture pain in chil-dren. Journal of Pediatric Nursing, 19(1), 33–39.

Shapiro, B. S. (1995). Treatment of chronicpain in children and adolescents. Pediatric Annals,24(3), 148–156.

Sinkin-Feldman, L., Tesler, M., & Savedra, M.(1997). Word placement on the Word-GraphicRating Scale by pediatric patients. PediatricNursing, 23, 31–34.

Tesler, M. D., Holzemer, W. L., & Spreker, M.(1999). Pain behaviors: Postsurgical responses ofchildren and adolescents. Journal of PediatricNursing, 13(1), 41–47.

Thompson, N. L. (2004). Hypnotherapy for chil-dren. Frederick, MD: Publish America.

Tobias, J. D. (2000). Tolerance, withdrawal, andphysical dependency after long term sedation andanalgesia of children in the pediatric intensive careunit. Critical Care Medicine, 28(6), 2122–2132.

Vincent, C. V. (2001). Nurses’ analgesic practiceswith hospitalized children. Journal of Child andFamily Nursing, 4(2), 79–89.

Vincent, C. V., & Denyes, M. J. (2004). Relievingchildren’s pain: Nurses’ abilities and analgesic prac-tices. Journal of Pediatric Nursing, 19(1), 40–50.

Willis, M. H. W., Merkel, S. I., Voepel-Lewis, T.,& Malviya, S. (2003). FLACC behavioral pain as-sessment scale: A comparison with the child’s self-report. Pediatric Nursing, 29(3), 195–198.

Wong, D. L., & Baker, C. M. (1988). Pain in chil-dren: Comparison of assessment scales. PediatricNursing, 14, 9–16.

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1231

lon23944_ch42.qxd 2/17/06 8:54 AM Page 1232

Documents

and Management in Children - · PDF fileDevelop a nursing care plan for assessing and ... Pain Assessment and Management in Children 1209 ... hypertension, pupil dilation, pallor,