PAIN MANAGEMENT IN CHILDREN ○ Herbal Therapies

Krizle Adaza ○ Biofeedback

○ Therapeutic Touch and Massage
OVERVIEW: ○ Transcutaneous Electrical Nerve Stimulation
● Pain ○ Heat or Cold Application
● Pain and Children ● Pharmacologic Pain Relief
● ADPIE ○ Topical Anesthetic Cream
● The Physiology of Pain ○ Oral Analgesia
○ Acute ○ Intramuscular Injection
○ Chronic ○ Intravenous Administration
○ Cutaneous ○ Patient -Controlled Analgesia
○ Somatic ○ Conscious Sedation
○ Visceral ○ Intranasal Administration
○ Referred ○ Local Anesthesia Injection
● Assessing the Type and Degree of Pain ○ Epidural Anesthesia
○ Infant
○ Toddler and Preschooler
○ School age and Adolescent
●

PAIN:
🌹🌹🌹
Ongoing Pain Relief

● Pain Assessment ● The sensation of pain is whatever the person experiencing it says it is
○ Pain Experience Inventory and it exist whenever the person says it does, McCaffery's (1979)
○ CRIES Neonatal Postoperative Pain Measurement Scale
○ COMFORT Behavior Scale PAIN AND CHILDREN
○ FLACC Pain Assessment Tool ● Many children are undermedicated because of common misconceptions
○ Poker Chip Tool about pain in children
○ Wong-Baker FACES Pain Rating Scale ● Nonpharmacologic interventions should be employed
○ OUCHER Pain Rating Scale ● Combinations of pharmacologic and nonpharmacologic interventions
○ Numerical or Visual Analog Scale are often most effective
○ Adolescent Pediatric Pain Tool ● Anesthetic cream should be used if possible
○ Logs and Diaries ● Medication routes preferred are oral and intravenous
● Pain Management ● Conscious sedation should be used for painful and frightening
● Nonpharmacologic Pain Management for Children procedures
○ Distraction ○ Tooth extraction
○ Substitution of Meaning or Imagery
○ Thought Stopping NURSING PROCESS OVERVIEW
○ Hypnosis ● Assessment
○ Aromatherapy and Essential Oils ○ Infant and Children can not verbalize feeling: trouble
○ Magnet Therapy communicating
○ Music Therapy ○ Children 3 years old: indicate pain by pointing to body part with
○ Yoga and Meditation pain
○ Acupuncture and Acupressure ■ Use poker chips and drawing faces
○ Crystal or Gemstone Therapy ○ Older school age children: some are reluctant to tell the truth
 ■ Use Pain scale 1-10 ■ Conducted by A-alpha and A-beta fibers
● Nursing Diagnosis ■ Example: pin prick
○ Focus on stress, fear, anxiety, and pain ○ Chronic pain
○ Pain r/t an invasive procedure ■ A pain that lasts for a prolonged period or beyond the
○ Fear r/t anticipation of painful procedure time span anticipated for healing
○ Disturbed sleep pattern r/t chronic pain ■ Lead to depression
○ Anxiety r/t planned dressing changes that cause pain ■ Threshold to sense pain lowers and creates a "feedback
● Outcome Identification and Planning loop"
○ Efficient pain control: anticipate when pain will occur and plan ○ Cutaneous pain
interventions to prevent it rather than let it occur and relieve it ■ Pain that arises from superficial structure: skin and
● Implementation mucous membranes
○ Choose a specific method best for each child ■ Example: Paper cut
○ Everyone involved in pain management must be aware of the ○ Somatic pain
child's specific way of expressing pain: signs and symptoms ■ Pain that originates from deep body structures: Muscles
○ If reluctant to admit pain due to injection: advocate for oral form or bone
of analgesia, intermittent IV infusion, or patient controlled ■ Example: Sprained ankle
analgesia ○ Visceral pain
○ Educate parents with: need for pain relief, proper doses, involve ■ Sensations that arise from internal organs: Intestines
them in assessment and evaluation process ■ Example: Appendicitis
● Outcome Evaluation ○ Referred pain
○ Check for nonverbal cues, vital signs and listen to the child's ■ Pain perceived at site distant from point of origin
statements ■ Example: The pain of right lower lobe pneumonia is often
thought to be abdominal pain because pain is referred or
THE PHYSIOLOGY OF PAIN felt in the abdomen
● Pain Conduction 4 major steps: ● Pain Threshold
○ Transduction ○ Point at which the child first senses pain
■ Sensing the pain sensation ○ Influenced by heredity
■ Begins in the peripheral nerveS when a stimulus ○ Varies person to person
activates nociceptors (specialized groups of sensory ● Pain tolerance
receptors) ○ Point above which a person is not willing to bear any additional
○ Transmission pain
■ Routing the pain sensation to the spinal cord ○ Affected by cultural influences
○ Perception ● Endorphins/Polypeptide
■ The brain interprets the sensation as pain ○ Released by pituitary and hypothalamus glands when pain is felt
○ Modulation ○ Stimulate opiates
■ Steps the body takes to relieve pain ○ Produce analgesia and a sense of well being
● Types of Pain:
○ Acute pain THEORIES OF PAIN AND PAIN MANAGEMENT:
■ Sharp pain ● Gate Control Theory of Pain
■ Occurs abruptly after an injury ○ Attempts to explain how pain impulses travel from a site of injury
■ Causes extreme distress and anxiety to the brain
 ○ Prevents the pain impulse from being received at the brain level ○ Difficulty comparing pain
and interpreted as pain ○ Difficulty describing intensity
○ Stimulated by 3 techniques: ○ Difficult to comfort because they have no perception of time - "It's
■ Cutaneous stimulation only for a minute"
● Skin stimulation ○ Some preschoolers do not mention pain because of their
● A-alpha and C fiber nerves responsible for egocentric thinking - assumes adults are already aware of their
transmitting pain impulse decreases pain
● Rubbing an injured part ○ Pain is punishment
● Applying heat or cold ○ Displays regression or withdrawal
● Suppresses pain by activating nearby peripheral ● School Age Child and Adolescent
fiber ○ Difficulty describing pain
■ Distraction ○ Assume like preschoolers - adults are already aware of their pain
● Allows the cells of the brainstem that register an ○ Regress with pain -baby talk or lying in fetal position
impulse as pain to be preoccupied with other ○ Children may be in middle school before they understand the
stimuli so a pain impulse cannot register use of pain rating scale
■ Anxiety reduction ○ Take note of clenched hands, clenched teeth, rapid breathing
● Pain impulses are perceived more by the brain if and guarding
anxiety is present
○ The effectiveness of this theory varies with: PAIN ASSESSMENT
■ Child's age
■ Ability to cooperate
■ Degree of pain
■ Time allowed for learning
■ Applying pain management
○ Best taught to children before they begin to have pain

ASSESSING THE TYPE AND DEGREE OF PAIN

Pain assessment in children is difficult because some children will suffer pain ● The Pain Experience Inventory
rather than report it. ○ Tool consisting of 8 questions for children and 8 questions for
the child's parents
● Infant
○ Restless, irritable
○ Crying
○ Grimacing, gritting of teeth, screaming, verbal expression of hurt
○ Touching or grabbing painful part of body
○ Clenched fists
○ Kicking, thrashing, attempting to push away stimulus
○ Cannot be comforted completely
● Toddler and Preschool
○ Limited vocabulary to describe pain
 ● The Poker Chip Tool
○ Uses 4 red poker chips placed in a horizontal line in front of the
child
○ Used with children as young as 4 years of age
○ Has the concept of "more" or "less"
● Wong -Baker FACES pain Rating Scale
○ 6 cartoon like faces ranging from smiling to tearful
● The Oucher Pain Rating Scale
○ Consist of 6 photographs of children's faces representing "no
hurt" to "biggest hurt you could ever have"
○ With vertical scale with numbers from 0-100
● The Numerical or Visual Analog Scale

● The CRIES Neonatal Postoperative Pain Measurement Scale

○ 10 point scale named for 5 physiologic and behavioral variables
associated with neonatal pain
○ C - crying
○ R - requires increased oxygen administration
○ I - increased vital signs
○ E - expression
○ S -sleeplessness
● The COMFORT Behavior Scale
○ Devised by nurses to rate pain in very young infants
○ Alertness, calmness/agitation, crying, physical movement,
muscle tone, and facial expression
● The FLACC Pain Assessment Tool
○ A scale by which healthcare providers can rate a young child's
pain when a child cannot give input
○ 5 types of behaviors that rates pain: ● The Adolescent Pediatric Pain Tool
■ Facial expression ○ Combines a visual activity and a numerical scale
■ Leg movement
■ Activity
■ Cry
■ Consolability
 ○ Example: A child could imagine a venipuncture needle as a
silver rocket ship probing a moon
● Thought stopping
○ Children learn to stop anxious thoughts by substituting a positive
or relaxing though in its place
○ Does not suppress thoughts but changes them to positive ones
○ Example: "It does not take long; my father will be with me; it's
important to help me get better"
● Hypnosis
○ Common pain management technique
○ Child needs to train with a therapist so at the time of pain, a child
can produce a trance-like state to avoid sensing pain
● Aromatherapy and Essential oils
○ Sense of smell plays a significant role in overall health
○ The brain responds to aromas with emotional responses
● Logs and Diaries ○ Essential oils penetrate cell walls and transport nutrients or
○ Children note when pain occurs and the intensity of the pain oxygen inside cells
each time it occurs ○ Example: Jasmine and Lavender oils relieves pain
○ Useful for chronic but intermittent pain ● Magnet Therapy
○ Magnets can control shift body energy lines to restore health or
PAIN MANAGEMENT relieve pain
● Pain management techniques like assessment techniques vary ○ Placebo effect than actual change in level of pain
depending on the age of a child, degree and type of pain experienced ○ Example: Copper, jewelry applied, magnets sewn into clothing or
● Children with chronic pain or pain not relieved with standard approaches shoes
may benefit from a referral to a pain management specialist or team ● Music Therapy
● A good rule for determining whether a child needs pain relief is to ○ Calming, relaxing, improves well being, serves a distraction
remember that - if it causes pain in an adult, it will cause pain in a child ○ Example: blasting music allows a great level of distraction
● Yoga and Meditation
NONPHARMACOLOGICAL PAIN MANAGEMENT FOR CHILDREN ○ Sanskrit word "Union"
Often called alternative or complementary therapies ○ Series of exercises that bring people closer to God
● Distraction ○ Increase heart rate efficiency
○ Shifting a child's focus from pain to another activity or interest ○ Slow respiratory rate
○ When choosing a distraction technique, make sure that they do ○ Low BP
not interpret "distraction" as just talking to the child or suggesting ○ Promote relaxation
a video game to divert attention ○ Reduce stress
○ Requires concentration which allows pain to breakthrough ○ Allaying anxiety
○ Example: Blowing bubbles ○ Release endorphins
● Substitution of Meaning or Imagery ● Acupuncture and Acupressure
○ A distraction technique to help a child.place another meaning on ○ Insertion of needles (meridian lines)
a painful procedure ○ Applying deep pressure at same points
○ Works well with quick and simple procedures ○ Not attractive for children and may add more stress
 ● Crystal or Gemstone Therapy ■ Goldenrod (urinary tract inflammation reduction)
○ Believed to have healing powers when placed in certain ● Biofeedback
positions around the body ○ Biofeedback apparatus is used to measure muscle tone or
○ Do not move gems for a child might feel he lose his powers child's ability to relax
● Herbal Therapies ○ Effective with adolescent
○ Make sure herbs taken do not interfere with prescribed pain ○ Less effective with preschool and school aged
medications ● Therapeutic Touch and Massage
○ Example: ○ Massage is rubbing or kneading of body parts to aid circulation
■ Mile tea (inflammation reduction) and relax muscle
■ Garlic (anti-inflammatory, anti cancer) ○ Based on a principle that body has energy fields
■ Ginger (Nausea or vomiting reduction) ● Transcutaneous Electrical Nerve
● Stimulation (TENS)
○ Used to manage acute or chronic pain ○ Causes: eye damage, and anesthetized gag reflex when
○ Children dislike TENS because it uses electric current ingested or rubbed in the eyes
○ Not recommended with a wounded skin that causes electrode to ○ OTC medication
get wet ● Oral Analgesia
● Heat or Cold Application ○ Uses/Medication:
○ Cold reduces pain by constricting capillaries and therefore ■ NSAIDs are excellent for reducing pain for rheumatic
reducing vessel permeability, edema and pressure conditions and sprained ankles
○ After 24 hrs of injury, apply heat because it dilates capillaries, ● Ibuprofen
increase blood flow and reduce edema ● Naproxen
■ Opiods are used for severe to acute pain
PHARMACOLOGIC PAIN RELIEF ■ Morphine
● Topical Anesthetic Cream ■ oxycodone
○ Uses ■ Hydromorphone
■ During lumbar puncture, bone marrow aspiration, and ○ Nursing Implication:
venipuncture ■ Children should not receive aspirin (acetylsalicylic acid)
○ Action for pain
■ Anesthetize skin before potentially painful procedures ■ Severe or acute pain use: opioids
○ Nursing Implications: ■ Never refer to as "Candy"
■ Applied to the site and covered with an occlusive ● Intramuscular Injection
dressing or plastic wrap: keep young ○ Analgesia are rarely given by this route
■ children from wiping away or tasting the cream ○ Risks
■ Wash site with soap or water, not alcohol: alcohol ■ Uneven absorption
removes natural body oil ■ Unpredictable onset of action
○ Dosage: ■ Nerve and tissue damage
■ Dollop of cream ○ As a rule, other routes are used whenever possible
■ Applied 1 hr before procedure ● Intravenous Administration
■ Applied 2-3 hrs before deeper procedures: lumbar ○ Uses
puncture, bone marrow aspiration ■ Most rapid acting route
■ Emergency situations
 ■ Acute pain ● Relieves anxiety, pain and depresses the child’s
■ Child requiring frequent doses of analgesia in whom memory of the event
gastrointestinal tract can not be used ● Intranasal Administration
○ Nursing Implications ○ Uses
■ Opiate analgesics can be given by bolus injection or ■ Attractive way to dispense medicine for children because
continuous infusion it’s easy for parents to administer and the medicine
■ If IV line is used advocate for intermittent infusion device absorbs well from the nasal mucous membrane
■ If toxicity with opioids occur, administer Naloxone ○ Action
(Narcan) ot anu opiate antagonist ■ Short duration in action: require repeat administration
○ Common Medications ○ Common Medication
■ Opioids: ■ Influenza Vaccine
● Morphine ■ Midazolam
● Fentanyl ● Short acting adjuvant sedative
● Hydromorphone (8x -10x stronger than morphine) ● Local Anesthesia Injection
■ Opioids side effects: ○ Uses
● Nausea, pruritus, vasodilation, cough ■ Suturing of lacerations
suppression, constipation ■ Bone marrow aspirations
● Patient -Controlled Analgesia ■ Peritoneal dialysis
○ Action: ○ Action
■ Allows patient or children (5-6 yrs old) to self administer ■ Stop pain transmission by blocking nerve conduction of
boluses of medication the impulse at the site of pain
■ The pump is sey with a lock out time so that after each ○ Nursing Implications
dose, the pump will not release further medication even if ■ The use of anesthetic cream before the injection can be
the button is pushed again: avoids overmedication helpful to relieve needlestick pain
○ Common Medication ○ Common Medication
■ Morphine ■ Lidocaine
● Conscious Sedation ● Epidural Anesthesia
○ Uses ○ Action
■ For procedures such as dental extraction, wound care, ■ Injection of analgesic agent into the epidural space
bone marrow aspiration,magnetic resonance imaging, outside the spinal canal
and endoscopy ○ Uses
○ Action ■ Provide analgesia to the lower body for 12 - 24 hrs
■ State of depressed consciousness usually obtained ■ Chest surgery or orthopedic
through IV analgesia therapy ■ Very effective for postoperative child in the 1st few days
■ Allows a child to be both pain free and sedated for a after surgery
procedure
■ Allows a child to respond to instructions during ONGOING PAIN RELIEF
procedures ● Used because of early discharge, the need for increased use of
○ Common Medication ambulatory surgery, and routine pain management at home
■ Chloral Hydrate ● Oral or IV analgesia can be administered by parents at home
● A sedative hypnotic analgesic combination ● Always provide instructions on:
○ Dosing
○ Administration
○ Frequency
○ Expected outcome
○ Expected level of relief
○ Telephone number of health care providers