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Hockenberry: Wong’s Nursing Care of Infants and Children, 10th Edition

Chapter 05: Pain Assessment and Management in Children
Key Points - Print

The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
(PedIMMPACT) recommends specific core domains to assess pain in children that include
pain intensity, global judgment of satisfaction with treatment, symptoms and adverse
events, physical recovery, and emotional response. Although the ability to measure pain in
children has improved dramatically in recent years, assessment of pain in children
continues to be complex and challenging.
Behavioral assessment is useful for measuring pain in infants and preverbal children
who do not have the language skills to communicate that they are in pain, or when mental
clouding and confusion limit a child’s ability to communicate. Behavioral pain
assessment may provide a more complete picture of the total pain experience when
administered in conjunction with a subjective self-report measure.
Physiologic measures are not able to distinguish between physical responses to pain and
other forms of stress to the body. Physiologic parameters, such as heart rate, respiratory rate,
blood pressure, palmar sweating, cortisone levels, transcutaneous oxygen, vagal tone, and
endorphin concentrations, reflect a generalized and complex response to stress. They are not
localized response to pain, but they provide useful information about general distress levels
of children experiencing pain.
The number of pain measures that are available for use in infants and young children has
increased dramatically and adds a layer of complexity to the assessment of pain in
Important components of assessment include the onset of pain; pain duration or pattern;
effectiveness of the current treatment; factors that aggravate or relieve the pain; other
symptoms and complications concurrently felt; and interference with the child’s mood,
function, and interactions with family.
Chronic pain is defined as pain that persists for 3 months or more or beyond the expected
period of healing. Complex regional pain syndrome and chronic daily headache are the
most common types of chronic pain conditions in children. Recurrent pain is pain that is
episodic and recurs. The time frame within which episodes of pain recur is at least 3
months. Recurrent pain syndromes in children include migraine headache, episodic sickle
cell pain, recurrent abdominal pain, and recurrent limb pain.
Pain is often associated with fear, anxiety, and stress. A number of nonpharmacologic
techniques, such as distraction, relaxation, guided imagery, and cutaneous stimulation, can
help with pain control.
The administration of sucrose with and without nonnutritive sucking has been demonstrated
to have calming and pain-relieving effects for invasive procedures in neonates.
One of the most significant improvements in the ability to provide atraumatic care to children
is the use of anesthetic creams such as LMX (lidocaine) or EMLA (a eutectic mix of local
Nonopioids, including acetaminophen (Tylenol, Paracetamol) and nonsteroidal
antiinflammatory drugs, are suitable for mild to moderate pain; opioids are needed for
moderate to severe pain. A combination of the two analgesics acts on the pain system on
two levels: nonopioids primarily act at the peripheral nervous system, and opioids primarily
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or infection. steroids for inflammation and bone pain. diphenhydramine for itching. such as fractures. gabapentin. amitriptyline. sprains. fibrinolysis. turning in bed. A significant advance in the administration of intravenous. is defined as pain that occurs at least once per month for 3 consecutive months. walking. Pain may be related to an operation. . and sometimes serious. Pain can also be related to chemotherapy and procedures such as bone Copyright © 2015. Surgery and traumatic injuries. which is typically delivered through a special infusion device. All rights reserved. involves repeated manipulations over the injured sites. physical therapy) is needed. The acute painful episode in sickle cell disease is the only pain syndrome in which opioids are considered the major therapy and are started in early childhood and continued throughout adult life. lacerations. Burn pain includes a constant background pain that is felt at the wound sites and surrounding areas. clonazepam) for neuropathic pain. A source of frustration for patients and clinicians is that most current analgesic regimens are inadequate in controlling some of the most severe painful episodes. This approach provides increased analgesia without increased side effects. and is severe enough that it interferes with a child’s normal activities. constipation is a common. it is difficult and challenging to control. or subcutaneous analgesics is the use of patient-controlled analgesia. particularly when pain is prolonged. antiemetics for nausea and vomiting. mucositis. not as a substitute for analgesics.Key Points . 2003. 1999 by Mosby. 2007. may be used alone or with opioids to control pain symptoms and opioid side effects. carbamazepine. the patient controls the amount and frequency of the analgesic.Print • • • • • • • • • • 5-2 act at the central nervous system. generate a catabolic state as a result of increased secretion of catabolic hormones. epidural. 2011. As the name implies. however. Burn pain is exacerbated (breakthrough pain) by movements such as changing position. imipramine) and antiepileptics (e. Poorly controlled acute pain can predispose patients to chronic pain syndromes. and burns. Although respiratory depression is the most feared side effect of opioids. accompanied by pain-free periods. Drugs frequently used to relieve anxiety.. side effect of opioids. and dextroamphetamine and caffeine for possible increased analgesia and decreased sedation. an imprint of Elsevier Inc.g. stool softeners and laxatives for constipation. a phantom limb. This leads to alterations in blood flow. A multidisciplinary approach that involves both pharmacologic and nonpharmacologic modalities (cognitive-behavioral intervention. Several harmful effects occur with unrelieved pain. strains. coagulation. which decrease peristalsis and increase anal sphincter tone. Because burn pain has multiple components. dislocations. or even breathing. known as coanalgesics or adjuvant analgesics. and water and electrolyte balance and increases the demands on the cardiovascular and respiratory systems. Other adjuvants include tricyclic antidepressants (e. Management of RAP is highly individualized to reflect the causes of the pain and the psychosocial needs of the child and family.g. Pain in children with cancer is present before diagnosis and treatment and may resolve after initiation of anticancer therapy.. and provide amnesia are diazepam (Valium) and midazolam (Versed). massage. substrate metabolism. and has changing pattern over time. Recurrent abdominal pain (RAP).. Areas of normal skin that have been harvested for skin grafts (donor sites) also are painful. Several drugs. these drugs are not analgesics and should be used to enhance the effects of analgesics. Inc. or functional abdominal pain. cause sedation. heat.

Pain triggers a number of physiologic stress responses in the body. Many patients at the end of life require doses of opioids that make them sedated but arousable as their disease progresses (cancer. Inc. AIDS.Key Points . Copyright © 2015. . Tumor-related pain frequently occurs when the child relapses or when tumors become resistant to treatment. Parents need reassurance that the opioids are treating pain but not causing the child’s death and that the child’s advancing disease is the cause of death. Unrelieved pain may prolong the stress response and adversely affect an infant’s or child’s recovery. Patients achieve comfort with a combination of opioids and adjuvant analgesics in most situations. whether it is from trauma. and they lead to negative consequences that involve multiple systems. or disease. A pain relief scale or periodic ratings of pain intensity should be used for evaluation of effectiveness of pain regimens. 1999 by Mosby.Print • • • • 5-3 marrow aspiration. 2011. The effectiveness of analgesics can be enhanced by a supportive attitude toward the child. particularly when pain is prolonged. an imprint of Elsevier Inc. cystic fibrosis. surgery. and lumbar puncture. the nurse can condition the child to expect pain relief. By reinforcing the cause and effect of the medication and analgesia. needle puncture. 2003.. neurodegenerative disease). Several harmful effects occur with unrelieved pain. provided the regimen is likely to be effective. 2007. Severe pain associated with invasive procedures and anxiety associated with diagnostic imaging can be managed with sedation and analgesia. All rights reserved. Several painful and invasive procedures require the administration of anesthetics and analgesics.