Introduction

Pain is defined as, whatever the experiencing person says it is, existing
whenever the experiencing person says it does. The International
Association for the Study of Pain has a definition that is widely used: Pain
is an unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage. Pain can
interfere with recovery from surgery or illness, prevent normal activity and
affect a child’s quality of life. The definition implies the attitude of children
toward pain using both verbal and nonverbal expression The American
pain society created the phrase “pain: as the
Fifth vital signs” to increase awareness of pain assessment among health
care professionals especially nurses. The rational is that if pain were
assessed seriousness as other vital signs, it would more likely to be treated
properly. The principle of pain assessment is to assess patients for pain
every time the nurses must checks for pulse, blood pressure, temperature,
and respiratory rate.
Prevalence and distribution of pain in children:

Several surveys have also been conducted to evaluate the prevalence of

acute pain in hospitalized children and adolescents. In a recent audit of the
epidemiology of procedural pain and pain management in 32 hospital units
in 8 pediatric hospitals in Canada, 2987 of 3822 children in the study had
undergone at least one painful procedure in the preceding 24hours with a
mean of 6.3 painful procedures per child. Of those who had painful
procedure, 78.1% had a pain management intervention recorded; however,
only 28.1% had one or more pain management interventions administered

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and documented especially for the painful
procedure.(Stevens2011

Amore recently study reported a prevalence rate of 27% of moderate to

severe pain in hospitalized children in USA. Adolescents and infants
exhibited higher prevalence rate of pain (38% and 32%) respectively than
other children (17%) .In addition, those hospitalized in surgical units
demonstrated much higher rates of moderate to severe pain (44%) than
those in medical units (13%)(Groenewaled 2012)
Physiology of pain
The sensation of pain is a complex phenomenon that involves a sequence
of physiologic events in the nervous system. These events are transduction,
transmission, perception and modulation.

Transduction: peripheral nerve fibers extend from the spinal cord to

various locations in and throughout the body's tissues, such as skin, joints,
bones and membranes covering the internal organs. At the end of theses
fibers are specialized receptors called nociceptors which become activated
by noxious stimuli. This stimulus can be chemical, thermal or mechanical.
Mechanical stimuli may include intense pressure to an area, strong muscle
contraction. Chemical stimuli may involve the release of mediators as
histamine, prostaglandine in response to tissue trauma or inflammation.
Thermal stimuli involves extreme of heat and cold. The activation of theses
nociceptors is called transduction.

Transmission: when nociceptors are activated by noxious stimuli, the

stimulus is converted into electrical impulses that are relayed along the
peripheral nerves to spinal cord and brain. Specialized afferent nerve fibers
are responsible for moving electrical impulse along. Myelinated A-delta
fibers are large fibers that conduct the impulse at very rapid rate. The pain

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transmitted by these fibers is often referred to as fast pain, most commonly
associated with mechanical or thermal stimuli. Pain also is transmitted by
small unmylinated C fibers . Theses fibers transmit the impulse slowly and
are often activated by chemical stimuli or continued mechanical or thermal
stimuli .these fibers carry the impulse to the spinal cord via the dorsal horn
.neurotransmitters are released to facilitate the transmission process to the
brain.

Perception: once in the dorsal horn of the spinal cord, the nerve fibers
divide and then cross to the opposite side and rise upward to the thalamus.
The thalamus responds quickly and sends a message to the somatosensory
cortex of the brain, where the impulse is interpreted as the physical
sensation of pain. the impulses carried by the fast A-delta fibers lead to
perception of sharp, stabbing localized pain that also commonly involves a
reflex response to withdraw from the stimulus .In addition to sending a
message to the cerebral cortex, the thalamus also sends a message to the
limbic system, where the sensation is interpreted emotionally, and to the
brain stem centers, where autonomic nervous system responses begin.
Modulation:

Once the brain perceives the pain, the body releases neuromodulators, such
as endogenous opioids (endorphins and encephalin), serotonin, nor
epinephrine, and gamma amino butyric acid. These chemicals hinder the
transmission of pain and help produce an analgesic, pain-relieving effect.
This inhibition of the pain impulse is called modulation. The descending
paths of the efferent fibers extend from the cortex down to the spinal cord
and may influence pain impulses at the level of the spinal cord.

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❖ Pain Transmission Theories
1- Specificity Theory :(specific pain receptor and pathway)

Specific stimulus has a specific receptor which goes to a location in the

brain. The specific location identifies the pain’s quality. Thus any
noxious stimulus applied to the surface of the skin results in a pain
sensation. The evaluation of the type of pain occurs in the brain.

2- The pattern Theory:

The pattern of stimulation (intensity over time and area), not the
receptor type, determines whether nociception occurs Alfred
Goldscheider (1894) proposed that over time, activity from many
sensory fibers might accumulate in the dorsal horns of the spinal
cord and begin to signal pain once a certain threshold of accumulated
stimulation has been crossed. That a signal carried from the area of
injury along large diameter "touch, pressure or vibration" fibers may
inhibit the signal carried by the thinner "pain" fibers - the ratio of
large fiber signal to thin fiber signal determining pain intensity. This
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was taken as a demonstration that pattern of stimulation (of large and
thin fibers in this instance) modulates pain
intensity.
3- Sensory Interaction Theory:
It is based on that the intensity of the stimulus and central summation
were the critical determinants of pain. This theory proposes that pain
is not a separate entity but results from over-stimulation of other
primary sensations (touch, light, sound, etc.)
4-Gate Control Theory:
This theory proposed by Ronald Melzack (Canadian psychologist)
and David wall in the 1962. This theory explain many aspects of
pain and how may be controlled by thoughts, emotions, and action.
This theory proposed that there is interaction between pain stimuli
and other sensation and that stimulation of fibers that transmit non
painful sensation blocks or decreases the transmission of pain
impulses through on inhibitory gating circuit. This inhibitory cell
contain encephalin , which inhibits the transmission of pain.
❖ Peripheral nerve fiber carrying pain to spinal cord can have their input
Modified at the spinal cord level before transmission to the brain.
There are snaps in the dorsal horn act as gates that close to keep
impulses from reaching the brain or open to permit impulses to ascend
to the brain.
Main Ideas of these theory
Pain impulses can be controlled by a gating mechanism in the
dorsal horn of the spinal cord to permit or inhibit transmission
Gating factors include effect of impulses transmitted over fast or
slow conducting nerve fibers and effects of descending impulses
from the brainstem and cortex. Substantia Gelatinosa (SG)in dorsal
horn of spinal cord act as gate.

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According to the gate theory

• small diameter nerve fibers carry pain stimuli through agate

• Large diameter nerve fiber going through the same gate can inhibit
the transmission of those pain impulses ( this is close the gate )

Factores closed gate

➢ Activity in the pain fibers- opens the gate.
➢ Activity in other sensory nerves-closes the gate.
➢ Message from the brain- concentrating on the pain or trying not to
think about it.

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Categories of pain: most commonly pain is classified based on its
duration, etiology, or sources or location.

Classification by source or location: - pain may also be classified by the

source or location of the area involved .It can be somatic pain (superficial
and deep) or visceral pain. Theses classifications typically indicate
nociceptive pain.

Somatic pain: refers to pain that develops in the tissues. It can be divided
into two groups superficial and deep. Superficial somatic pain
(cutaneuose) arises from stimulation of pain receptors in the skin,
subcutaneous tissues, or mucous membranes. Typically the pain is well
localized and described as sharp, pricking or burning sensation. It may be
due to external mechanical, thermal or chemical injury or skin disorders.

Deep somatic pain typically involves the muscles, tendons, joints fasciae
and bones. it can be localized or diffuse and is usually described as dull,
aching or cramping .it may be due to strain from overuse or direct injury ,
ischemia or inflammation. The person may exhibit sympathetic nervous
system activation such as tachycardia, tachyapnea, hypertension pallor
and papillary dilatation.

Visceral pain: is caused by infiltration, distention, compression, or

distortion of organs within the thorax, abdomen and pelvis. It is often
produced by a disease, typically described as vague, dull discomfort, this
type of pain may be difficult to localize, because it may be referred to
superficial sites removed from the involved organ (eg, visceral pain
related to hepatomegally with radiation to the right shoulder)
Classification by duration

Acute pain: is an important biological protective mechanism, much like

an alarm, notifying the body of harm and promoting a person to avoid
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further injury. Acute pain is associated with at least initially, sympathetic
autonomic system activity .uncomplicated acute pain is self-limiting and
brief (lasting only hours to few days) and generally disappears when the
injury heals. A recurrence of acute pain may signal a serious problem, such
as an abscess. It is the most common pain experienced by infants and
children .They usually experience it as a result of injuries and accidents
that are normal part of growing or as a result of invasive painful
procedures.
Procedure-related pain:. Defined as pain caused by a diagnostic or
treatment procedure in the conscious patient (e.g. venepuncture, lumbar
puncture, dental). These procedures, although sometimes perceived as
intensely painful by children, are not necessarily tissue damaging or
invasive (e.g. physiotherapy).

Chronic pain: persists long after the initial acute injury or disease lasting
for as long as 3to6 months after the healing has presumed to have occurred
.In contrast to acute pain, chronic pain is rarely associated with signs of
sympathetic nervous system arousal. As pain becomes prolonged and
continuous, the autonomic nervous system response tends to diminish. It
may be continuous or intermittent it often interferes with sleep and
performance of activities of daily living. The lack of objective signs may
lead an inexperienced clinician to wrongly conclude that a child doesn’t
have pain. For children, most chronic pain complaints are idiopathic in
nature resulting in a cycle of fear and anxiety. Classification
by the etiology: pain can be classified by the etiology as nociceptive or
neuropathic

Nociceptive pain: is associated with acute tissue injury or acute

inflammation. This type of pain is an expected result of injury, associated
with normal nerve transmission processes and usually resolves with

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healing. It ranges from sharp or burning ,to dull, aching or cramping and
to deep aching or sharp stabbing examples of conditions that result in
nociceptive pain include chemical burns, cuts appendicitis and bladder
distension.

Neuropathic pain: resulting from injury to, inflammation of or

dysfunction of the peripheral or central nervous system. It can be described
as burning, electric, prickly or shooting. Children use words as bugs biting
or needles to describe such pain. Examples of neuropathic pain include post
surgical peripheral nerve injury and post stroke pain. Neuropathic pain is
less understood than nociceptive pain.
Factors influencing pain

Children like adults experience neurologic events that result in the

perception of pain. However research has found that environmental and
psychological factors may exert a greater influence on the child's
perception of pain. Certain factors such as age, gender, cognitive level,
temperament, previous pain experiences, and family and cultural
background cannot be changed. However, situational factors involving
behavioral, cognitive, and emotional aspects can be modified. Theses
situation-specific factors that affect the child's pain experience include
what the child and parents understand, what they and the health care staff
do and how the child and parents feel.
1-Age: Younger children display more distress and rate their pain
intensity higher than older children. Only older children can differentiate
‘‘pain’’ from ‘‘unpleasantness’’ and ‘‘fear. Older children may be more
able to contain their behaviors or may desire to appear stoic, resulting in
lower pain ratings, not in lower pain sensations.
2-Cognitive level: cognitive level is a key factor affecting the child’s pain
perception and response cope with painful events. Toddlers have words to

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describe pain and can engage in non cognitive coping such as seeking
comfort. Young school-aged children can begin to use cognitive coping
skills. Only older adolescents are able to understand and describe such
complex concepts as the value of pain. Numerous research studies have
revealed that younger children often describe pain in concrete terms,
whereas older children use more abstract terms that involve both physical
and psychological components (49).
3-Developmental considerations
Children and adolescents experience the same amount of pain as adults do
for similar procedures and in many cases even more. Children’s
understanding of pain and its relief is thought to follow Piagetian
developmental stages, therefore pain measurement and management needs
to be developmentally appropriate. For example, in one study, children
who received age-appropriate information about their upcoming medical
procedure displayed less overt distress than those receiving age advanced
information.
4-Gender: gender and sex also may play a role in a child's perception of
pain, but research has failed to yield concrete evidence supporting it. It has
been suggested that boys and girls differ in how they perceive and cope
with pain and respond to analgesics. This may be influenced by various
factors including genetics, hormones, family culture .
5-Ethnicity: Adult studies have demonstrated interethnic differences in
pain ratings. Pain ratings are generally higher in black ones and Hispanics
than in white ones. Research in ethnic differences in children’s pain
response has been minimal.
6- Previous pain experiences
A child identifies pain based on his or her experiences with pain in the past.
Previous pain experience with inadequate pain control may lead to
increased distress during future painful procedures.

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7- Family and culture
The child's cultural and family background will influence how he or she
will express and manage pain. Some cultures transmit the standard of
accepting pain stoically; others allow outward expression. The parents
have a strong influence on the child's ability to cope. If a parent reacts to
the child's pain in a positive manner and offers comfort measures, the child
may have an easier time coping .If the parent shows anger or disapproval,
the pain experience may be intensified for the child.
8- Pain sensitivity, coping, and anxiety. Studies of temperament have
shown some effects on children’s pain responses, with children rated as
‘‘difficult’’ having greater pain responses and those rated as ‘‘adaptable’’
displaying a less distress. Evidence exists for an identifiable pain-sensitive
profile and for a familial predisposition to pain sensitivity. High anxiety
results in a greater pain response. Pain coping style influences the pain
response, with those using distraction reporting a lower pain. Parental
prediction of the child’s reaction, which is much more readily obtainable
than the results of formal temperament, pain-coping style, or anxiety
assessments, correlates strongly with children’s pain responses
9-Parental presence: The effect of parental presence on children’s pain
and distress response has been mixed and likely depends on the parents’
own anxiety level, parent child interactions, and the parent’s ability to help
the distress includes reassurance, criticism, apology, and giving control to
the child (An overall control of the procedure, not choices).Reassurance is
commonly used by parents and staff decrease children’s distress.
10-Preparation: Pre procedural information, given to the child by health
care workers or parents; especially, information on the sensations to be
expected and information aimed at enhancing realistic expectations, has
been associated with reduced distress in children.

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11-Use of interventions: Although a body of literature supporting the
efficacy of pharmacologic and non pharmacologic interventions exists,
there is a gap between what we know works and how we actually practice
Consequences of pain
Pain is a major source of stress for children and their families as well as for
health care providers. If left unmanaged, pain in children can lead to
serious physical and emotional consequences such as increased oxygen
consumption and alteration in blood glucose metabolism. Inadequately
controlled pain can have long lasting negative outcomes such as increased
distress during later procedures, non adherence to treatment regimens,
inactivity, prolonged bed rest and the development of chronic pain.
Detrimental effects on the course of the disease itself may also be seen with
untreated pain.
Pain assessment:

Pain assessment is a critical component of the nursing process.

Unfortunately, health professionals including nurses tend to underestimate
the existence of pain in children.
One approach to pain assessment in children is QUESTT.

Question the child

Use pain rating scales.

Evaluate behavior and physiologic changes.

Secure parents involvement

Tack cause of pain into account

Tack action and evaluate results.

❖ Question the child: children's verbal statements and description of pain

are the most important factors in assessing pain. However young
children may not know what the word pain means and may need help

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 in describing it using familiar language. Therefore using a varity of
words to describe pain, such as, hurt boo-boo. If appropriate is
necessary.
❖ Questioning the parents: Parents play a key role in assessing pain in
children as they can provide information about the child's current and
past experience with pain. In addition, they can provide information
about how the child exhibits and responds to pain .They also may be
aware of subtle changes in the child's behavior that may precede the
pain, occur with pain or indicate relief of pain.
❖ Use a pain rating scale: pain rating scales (tools) provide a subjective
quantitative measure of pain. Although various pain scales exist, not
all of them are appropriate for young children. For the most valid and
reliable pain intensity rating, a scale is selected that is suitable to the
child's age, abilities and preference.
Three main methods are currently used to measure pain intensity: self
report, behavioral, and physiological measures. Self-report measures
are optimal and the most valid .Both verbal and nonverbal reports require
a certain level of cognitive and language development for the child to
understand and give reliable responses. Children’s capability to describe
pain increases with age and experience, and changes throughout their
developmental stages. Although, observed reports of pain and distress
provide helpful information, particularly for younger children, they are
reliant on the individuals completing the report. Behavioral measures
consist of assessment of crying, facial expressions, body postures, and
movements. They are more frequently used with neonates, infants, and
younger children where communication is difficult.

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 1- Self report measures include:
A. Pain Faces Scale (Preschoolers ) by age of 4

B- Poker Chip Tool : It is a tool that was developed for preschoolers to

assess “pieces of hurt” . The tool uses four poker chips, where one chip
symbolizes “a little hurt” and four chips “the most hurt you could
experience”. The tool is used to assess pain intensity. Health care
professionals align the chips in front of the child on a flat surface, and
explain, using simple terms, that the chips are “pieces of hurt”. The child
is asked “how many pieces of hurt do you have right now?

C-The OUCHER Scale: It is used for children older than 5 years. The
tool has two separate scales: the numeric scale (i.e., 0–100) and the
photographic scale usually used for younger children. The photographic
scale entails six different pictures of one child, portraying expressions of
“no hurt” to “the biggest hurt you can ever have”. Children are asked to
choose the picture or number that closely corresponds to the amount of
pain they feel.

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D-Visual Analogue Scale (VAS):
It is a horizontal line, 100mm in length, attached to word descriptions at
each end, “not hurting” or “no pain” to “hurting a whole lot” or “severe
pain.

— D. Numerical rating scale

—
E-Pediatric Pain Questionnaire. It is a self-report measure to assess
children and adolescents coping abilities using 8 subscales “information
seeking, problem solving, seeking social support, positive self-
statements, behavioral distraction, cognitive distraction, externalizing

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and internalizing as well as three more complex scales (approach,
distraction, and emotion-focused avoidance) .It contains 39 items in
total, with scores ranging from 1 (“never”) to 5 (“very often”). Children
or adolescents are requested to state how often they “say, do, or think”
certain items when they hurt or in pain. The questionnaire usually takes
about 10–15 minutes to complete.

F-Adolescent Pediatric Pain Tool (APPT): It is a valid all encompassing

pain assessment tool used for individual pain assessments and measures
intensity, location, and quality of pain in older children usually between 8
and 17 years of age. The APPT is most useful with children and adolescents
who are experiencing complex, difficult to manage pain. It consists of a
body map drawing to allow children to point to the location of pain on their
body and a word graphic scale to measure pain intensity. The word graphic
rating scale is a 67 word list describing the different dimension of pain and
a horizontal line with words attached that range from “no,”“Little,”
“medium,” “large,” to “worst” possible pain .The child is instructed to
color the area where he or she is hurting and color it as big or small as how
much he or she is hurting.
The third assessment is a list of words that may be used to describe pain
such as throbbing, stabbing or sharp.

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2- Behavioral measures
Nonverbal children: physical and behavioral indicators are used to
quantify pain in nonverbal children and rely on the nurse's observation of
the child pain behavior scales involve assessing behaviors that have been
identified as indicators of pain. The number identified using a pain
behavior scale .They are more frequently used with neonates, infants, and
children where communication is difficult. such as the neonatal younger
infant pain scale (NIPS) and the FLACC behavior pain assessment scale,
Children's Hospital of Eastern Ontario Pain scale , Toddler preschooler
post operative pain scale ( TPPPS), COMFORT scale that is used in critical
settings, and The Observational Scale of Behavioral Distress (OSBD) is
among the most widely used scales in this category.

1- Neonatal Infant Pain Scale (NIPS). It is a behavioral

assessment tool to measure pain. The scale takes into account pain
measurement before, during and after a painful procedure, scored in one-
minute intervals. The indicators include: face, cry, breathing pattern, arms,
legs, and state of arousal. Results are obtained by summing up the scores
for the six indicators (where 0 indicates no pain, and 2 indicates pain), with
a maximum sore of 7. It is a good system to measure responses to acute
painful stimuli. .

2-The Faces Legs Activity Cry Consolability Scale (FLACC).

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It is a behavioral scale for measuring the intensity of Post procedural pain
in young children. It includes five indicators (face, legs, activity, cry, and
consolability) with each item ranking on a three point scale (0–2) for
severity by behavioral descriptions resulting in a total score between 0–10.
F LACC is an easy and practical scale to use in evaluating and measuring
pain especially in pre-verbal children from 2 months to 7 years.

3-The COMFORT Scale. : It is a behavioral scale used to measure distress

in critically ill unconscious and ventilated infants, children, and
adolescents. This scale is composed of 8 indicators: alertness,
calmness/agitation, respiratory response, physical movement, blood
pressure, heart rate, muscle tone, and facial tension. Each indicator is given
a score between 1 and 5 depending on behaviors displayed by the child and
the total score is gathered by adding all indicators (range from 8–40).
Patients are monitored for two minutes. The COMFORT scale has been
proven to be clinically useful to determine if a child is adequately sedated.

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4-The Children’s Hospital of Eastern Ontario Pain Scales (CHEOPS). It
is one of the earliest tools used to assess and document pain behaviors in
young children. It used to assess the efficacy of interventions used in
alleviating pain. It includes six categories of behavior: cry, facial, child
verbal, torso, touch, and legs. Each is scored separately (ranging from 0–2
or 1–3) and calculated for a pain score ranging from 4–13. Its length and
changeable scoring system among categories makes it complicated and
impractical to use compared to other observational scales.

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5-The Observational Scale of Behavioral Distress (OSBD). It remains
the most frequently used measurement in procedure-related distress studies
.The number of distress behaviors on the OSBD-R was reduced to eight.
The behaviors assessed in the OSBD-R include cry, scream, restraint,
verbal resistance, information seeking, emotional support, verbal pain and
flail. The behaviors are usually organized into categories of growing
intensity, considering their level of interference with medical procedures
Both the OSBD and OSBD-R are unique in that distress behaviors are
weighted on a 1–4 point scale to reflect the intensity of
distress.

6-The Toddler-Preschooler Postoperative Pain Scale (TPPPS). It is

used to assess pain in young children during and after a medical or surgical
procedure. It is most commonly used for children aged 1–5 years. In order
to observe verbal, facial, and bodily movement, the child needs to be
awake. This scale relies on behavioral observations, but also includes a self
report element. The TPPPS includes seven indicators divided into three
pain behavior groups: vocal pain expression, (verbal complaint, cry, moan)
facial pain expression (open mouth, squinted eyes, brow bulging and
furrowed forehead) and bodily pain expression (restlessness, rubbing
touching painful area). It is a useful tool for evaluating the effectiveness of
medication administration in children, but does not measure pain intensity.
If a behavior is present during a 5-minute observation period, a score if 1
is given whereas a score of 0 is given if the behavior was not present. The
maximum score obtained is 7, which indicates a high pain intensity
.

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 3- Physiological measures

— Studies of physiological responses to pain in infants and children often

include heart rate, vagal tone (parasympathetic inhibitory influence on
the heart), blood pressure, respiration rate, oxygen saturation rate,
palmer sweating, restlessness, and dilatation of the pupils. However
these sign vary considerably for example heart rate may actually
decrease and may be produced by emotions such as fear and anxiety.
They occur primarily in acute pain from stimulation of sympathetic
nervous system. If pain persists the body begins to adapt and these
response decrease or stabilize. Reviews of research evidence
demonstrate several challenges associated with interpreting
physiological responses to painful events. First, pain is a stressor, and
physiological responses to various types of stress are similar and not
unique or specific to noxious stimuli.

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Second, these measures have been used to study responses to short-
duration, sharp pain, and physiological responses to long-term pain
appear to habituate.

Finally, the general health and maturational age of the infant or child also
may influence physiological responses to pain. Consequently,
physiological indicators of pain are used in conjunction with other
measures.

❖ Evaluate behavioral and physiologic changes:

Behavioral changes are common indicators of pain and they are especially
valuable in assessing pain in nonverbal children. Observe for physical
signs and symptoms of pain, keeping in mind the child's developmental
level.

❖ Take cause of pain into account:

When children exhibit behaviors or other clues that suggest pain, reasons
for discomfort should be investigated. Pathology may give clues to the
expected intensity and type of pain. For example, pain caused by bone
marrow puncture is typically greater than the discomfort associated with a
vein puncture. However, it is a mistake to believe that certain conditions or
procedures always produce a standard amount of pain. For example, Sore
throat pain may be mild or sever only the child knows the intensity.

❖ Take action and evaluate results:

The reason of assessing pain is to relive it .Total pain relief should be the
goal, with the combined use of pharmacologic and non pharmacologic
interventions. Regardless of the type of pain interventions, evaluation of
the results is essential. No one pain reduction technique is effective for all

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children .Therefore a pain assessment record is used to monitor the
effectiveness of the interventions.

Pain management: is the alleviation of pain or reduction in pain to level

of comfort that is acceptable to the patients. It includes
A- Pharmacologic intervention .
B- Non-pharmacologic intervention

1.Pharmacologic Interventions

Using pharmacological method to control pain requires attention to four

"Rights" right drug right does right rout and right time. There are two
primary groups of pain medications: non opioid and opioid. A third group
of drugs called adjuvant or analgesics, address symptoms that often
accompany pain, such as insomnia, anxiety, muscle spasm, anorexia, and
depression.

1- Non opioid Analgesics

Non opioid analgesics relieve pain by acting on peripheral nerve
endings at the injury site to decrease the level of inflammatory
mediators. This group of analgesics includes drugs such as
acetaminophen (Tylenol) and non steroidal anti-inflammatory-drugs
(NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen
(Motrin). The specific actions and dosages of these analgesics vary.
Generally speaking, however, they have analgesic, antipyretic, and
anti-inflammatory effects and are useful for mild to moderate pain
With the exception of acetaminophen, most non opioid are potent anti-
inflammatory agents. These drugs are especially effective when the
primary cause of pain is inflammation, as occurs in rheumatoid
arthritis and bone cancer.

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 2. Opioid Analgesics
Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and
include such drugs as morphine, codeine, and methadone. These
Opioid works at the level of the central nervous system, decreasing the
perception of pain. The primary action of opioid (narcotics) is to
alleviate moderate to severe pain. Many of the unwanted effects of this
class of drugs are related to their actions on systems of the body other
than the CNS, causing such effects as constipation and respiratory
depression.

3. Adjuvant Analgesics

Adjuvant analgesics (co-analgesics) are drugs that were developed for

uses other than pain but have been found to enhance the effects of
analgesics. Caregivers need to remember that these are “helper drugs,”
not substitutes for analgesics. Clients in pain still need analgesic .UUU

2-Non pharmacologic measures : Distraction is the most frequent

intervention used in the emergency department to guide children’s
attention away from the painful stimuli and reduce pain and anxiety. It is
most effective when adapted to the developmental level of the child.
Distraction techniques are often provided by nurses, parents or child life
specialists. Current research has shown that distraction can lead to the
reduction in procedure times, and the number of staff required for the
procedure. Distraction has also proven to be more economical than using
certain analgesics. Distraction is divided into two main categories: passive
distraction, which calls for the child to remain quiet while the health care
professional is actively distracting the child (i.e., by singing, talking, or
reading a book). Active distraction, on the other hand, encourages the
child’s participation in the activities during the procedures. Interventions

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used to minimize pain are classified into three main categories (cognitive,
behavioral, or combined).
✓ Cognitive Interventions. They are mostly used with older children to
direct attention away from procedure-related pain (e.g., counting,
listening to music, non procedure related talk). The following are a
few examples of cognitive interventions:
(1) Imagery. The child is asked to imagine an enjoyable item or experience
(e.g., playing on the beach).
(2) Preparation/Education/Information. The procedure and feelings
associated with the procedure are explained to child in an age appropriate
manner. The child is provided with instructions about what he/she will
need to do during the procedure to help them understand what to expect
(3) Coping statements. The child is taught to repeat a set of positive
thoughts (e.g., “I can do this” or “this will be over soon”) .
(4) Parental training. The parents or family members are taught one of
the above interventions to decrease their stress, as decreasing the parent’s
distress will often lead to a decrease in the child’s distress.
(5) Video games and television. These may be used to distract children
from the painful procedures.
✓ Behavioral Interventions. They are behavioral methods to guide the
child’s attention away from procedure-related pain. (e.g., videotapes,
games, interactive books). A few examples are:
(1) Breathing exercises. The child is taught to concentrate on deep
breathing. To engage younger children, health care professionals can use
party blowers, or blowing bubbles.
(2) Modeling positive coping behaviors. The child may watch another
child or adult going through the procedure, and rehearse these behaviors
(3) Desensitization. This is a step-by-step approach to coping with the
painful stimuli. It involves slowly introducing the procedure and tasks

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involved, and effectively dealing with easier tasks before moving to the
next one.
(4) Positive reinforcement. The child is rewarded with positive statements
or concrete gifts, after the painful procedure (e.g., stickers, toys, games,
small trophies)
(5) Parent coaching. The parents are instructed to enthusiastically
encourage the child to use these strategies.
Current studies are beginning to take into consideration children’s different
responses to distraction interventions based on their developmental stage,
maturity level, and age.
 Neonates and Infants. When performing painful procedures on
infants, it is important to take into consideration the context of the
procedure (i.e., is the procedure really necessary, how many painful
procedures has the infant had in the past, and what was their previous
pain experience)
Distraction techniques used with this age group are mostly passive.
Cognitive strategies used to reduce pain perception in infants are either
visual or auditory interventions. Visual aids can include pictures, cartoons,
mobile phones, and mirrors. Auditory aids include music, lullabies sung by
parents or health care professionals. Music is more
frequently being used to improve painful outcomes in infants.

Behavioral strategies are more common for this age group, and involve
either “direct or indirect” interventions that engage the caregivers in
handling the infants.
Examples of behavioral strategies include the following:

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 Neonates and Infants
(1) Non-nutritive sucking, an indirect intervention involving insertion of
a pacifier or a non lactating nipple into the infant’s mouth to encourage
sucking behaviors, was found to stimulate the or tactile and mechano
receptors, and decrease cry durations and heart rate .
(2) Skin to skin contact with the mother (kangaroo care), where the infant
is positioned on the mother’s exposed chest during, or after the painful
procedure.
(3) Rocking and holding the infant, where the infant is carried by a parent
or caregiver during (if possible) and after the painful procedure and gently
rocked
(4) Swaddling the infant is another similar calming technique where the
infant is wrapped with its extremities close to their trunk to prevent him/her
from moving around excessively.
✓ Toddlers and Preschoolers. For young children, explaining the
procedures with age appropriate information is useful, in addition to
providing them with the opportunities to ask questions. Examples for
active distraction used with this age group include, allowing them to
blow bubbles, providing toys with lots of colour or toys that light up.
Initiating distracting conservations (e.g., how many brothers and sisters
do you have? What did you do at your birthday party?) and deep
breathing methods are also helpful for older children. Passive
distraction techniques include: having the parents or child life specialist
read age appropriate books, sing songs, and practicing “blowing out
birthday candles” with the child.
✓ School-Aged Children. Older children have a better understanding of
procedures and why they are being done, thus providing them with age
appropriate information is also important. Providing children with a
choice (e.g., sit or lie down, choose which hand) helps them feel in

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 control of the situation. Asking parents about their child’s previous pain
experiences and coping mechanisms helps health care professionals
identify appropriate interventions to use with the child. Educating
school-aged children about passive and active techniques available will
help them cope with the distress and anxiety of the procedure. Active
techniques for this age group include blowing bubbles, singing songs,
squeeze balls, relaxation breathing and playing with electronic devices.
Passive distraction can include watching videos, listening to music on
headphones, reading a book to the child or telling them a story.
✓ Adolescents. It is essential to always ensure a private setting for
procedures with adolescents especially as they sometimes tend to deny
pain in front of friends, and family. Giving them the power to choose
the type of distraction, or whether they want friends and family present
is helpful. Striking conversations, using squeeze balls or having them
play with electronic devices are examples of active techniques, while
passive distractions include watching videos, training them to breathe
deeply (in from the nose, count to 5 and out through the mouth), and
listening to music.

NURSING ROLE IN PAIN MANAGEMENT:

The role of the nurse in assessment and management of pain
varies according to:

28
1) Type of pain being cared e.g. age, sex, educational level, diagnosis,
expected prognosis, medical management.
2) Setting in which care is delivered.
3) Educational background and experience of individual nurse.

The nursing function of appropriate pain management includes, but

is not limited to:
• Ensuring informed consent for pain management.
• Assessing pain and evaluating response to pain management
interventions using a standard pain Management scale based on
patient self-report.
• Educating staff, patients, and families regarding the difference
between tolerance, physical dependence,
And addiction in relation to pain relieving medications, and the low
risk of addiction from long-term use And or high doses of opiates
for pain relief
• Educating patients and families in a culturally competent manner
regarding appropriate expectations for Pain management.
• Recognizing that pain medications may be given around-the-
clock.
• Intervening to treat pain before the pain becomes severe.
• Using non-drug interventions to assist in pain alleviation.
• Using knowledge of equal analgesic dosages to maintain both
patient safety and pain relief as routes and Types of ordered drugs
change.
• Documenting pain assessment, intervention, and evaluation
activities in a clear and concise manner.
• Intervening to minimize drug side effects.
• Implementing quality assurance/improvement standards to monitor
the pain management program

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 • Nurses should start intervention before the level of pain becomes
unbearable.

• Because pain is a subjective experience nurses should maintain

good communication pattern with their patients.

• The nurse should respect and does not ignore patient`s complain

• All people have the right to have their pain relived even with
use of opioid, and even if they have a history of substance
abuse.

• Nurses should continue pain management even if persons

become unresponsive.

• Nurses should encourage continuity of care within and across

health care setting for the achievement of effective pain
management.

• An interdisciplinary approach to pain management should be

reinforced by nurse advocacy for their patients.

• Sedation is an acceptable mean of pain management when all

other reasonable have failed

• The nurse should assist in treatment modalities such as :

• Range of motion exercises.
• Position change.
• Comfort measures.
• Application of hot or cold packs.
• Music therapy.
• Peer support group.

➢ Researches in Pediatric Pain Management:

1- Effect of interactive distraction versus coetaneous stimulation for vein
puncture pain relief in school age children.

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This study aimed to examine the effectiveness of the interactive
distraction versus coetaneous stimulation for venipuncture pain relief

This study concluded that; interactive distraction technique had a

positive pain relive effect and was better than coetaneous stimulation in
relieving children’s pain during vein-puncture on school age children

2-Use of Complementary and Alternative Medical Interventions for

the Management of Procedure-Related Pain, Anxiety, and Distress in
Pediatric Oncology
The purpose of this integrative review was to identify evidence
regarding the effectiveness of CAM intervention either alone or as an
adjunct to pharmacological therapy, in alleviating procedure-related
pain, anxiety, and distress in children and adolescents with cancer.
Results suggest that mind–body interventions, including hypnosis,
distraction, and imagery, may be effective, alone or as adjuncts to
pharmacological interventions, in managing procedure-related pain,
anxiety, and distress in pediatric oncology.

3-The Effect of Distraction Technique on the Pain of Dressing

Change among 3-6 Year-old Children.

The present study was designed and conducted to determine the effect
of distraction on pain of dressing second degree burn in 3-6 year-old
children.

According to the results it seems that distraction intervention has a

significant positive effect on the pain of dressing change in children.

4 -Analgesic Effect of Distraction during Venipuncture

in Children with Thalassemia.

31
 The purpose of this study was to test analgesic effect of distraction
during venipuncture in Children with Thalassemia.

Results: Distraction was demonstrated to be effective in reducing

pain among children undergoing venipuncture.

5- Effectiveness of cartoon distraction on pain perception and

distress in children during intravenous injection.

The aim of the study was to determine the effectiveness of “Cartoon

Distraction” as a strategy to reduce the pain perception and distress.

It was concluded that cartoon distraction is an effective distraction

strategy to reduce pain and distress among children during intravenous
injection.

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