NURS 3450 Ch 9 ATI Pediatric Pain Management – Flashcards
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Children of what age can perceive pain?
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All ages
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Unrelieved pain is a major _____ and _____ stressor.
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Physiologic, psycologic
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What can repeated pain in infants lead to?
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Future sensitivity to pain
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What can self-protective behavior due to pain cause?
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Delayed healing
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List pain behaviors for acute pain.
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Short attention span, irritability, grimacing, posturing, limb flexion, sleep disturbances, lethargy, withdrawal
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List pain behaviors for chronic pain.
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Physiologic adaptation may mask signs
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How should a developmentally appropriate pain scale be chosen?
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Determine child's ability to demonstrate concepts of degree, rank order, estimation, and classification
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List the 6 types of self-report scales.
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-Body outline -Faces -Oucher -Poker chip -Numeric rating -World-graphic rating
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List the factors that can have a positive or negative effect on pain perception.
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-Age -Developmental stage -Chronic or acute disease -Socioeconomic status -Prior experiences with pain -Personality -Family dynamics -Culture
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A loud cry is a developmental characteristic of pain in what age group?
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Young infant and older infant
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A rigid body/thrashing is a developmental characteristic of pain in what age group?
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Young infant
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A local reflex withdrawal from a painful stimulus is a developmental characteristic of pain in what age group?
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Young infant
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Lowered and drawn together eyebrows are a developmental characteristic of pain in what age group?
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Young infant
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Tightly closed eyes are a developmental characteristic of pain in what age group?
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Young infant
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An open mouth in a squarish shape is a developmental characteristic of pain in what age group?
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Young infant
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A facial expression of pain is a developmental characteristic of pain in what age group?
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Older infant
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Deliberate withdrawal from pain is a developmental characteristic of pain in what age group?
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Older infant
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A loud cry/scream is a developmental characteristic of pain in what age group?
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Toddler; school age
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Verbal expression of pain is a developmental characteristic of pain in what age group?
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Toddler; School age
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Thrashing of extremities is a developmental characteristic of pain in what age group?
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Toddler; school age
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Attempt to push away or avoid a painful stimulus is a developmental characteristic of pain in what age group?
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Toddler; school age
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Noncooperation is a developmental characteristic of pain in what age group?
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Toddler; school age
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Clinging to a significant person is a developmental characteristic of pain in what age group?
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Toddler; school age
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What is the main difference between developmental characteristics of pain in toddlers and school age?
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-Toddler: behaviors occur in anticipation of painful stimulus -School age: behaviors are less intense in the anticipatory phase and more intense with painful stimulus
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Stalling behavior is a developmental characteristic of pain in what age group?
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School age
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Muscular rigidity is a developmental characteristic of pain in what age group?
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School age
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Verbal expression of pain with less protesting is a developmental characteristic of pain in what age group?
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Adolescent
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Muscle tension with body control is a developmental characteristic of pain in what age group?
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Adolescent
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What is the minimum age to use self report pain scales?
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4 years
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What assessment tool is appropriate for children >3 years old?
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FACES
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What assessment tool is appropriate for children 2 months-7 years?
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FLACC
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What assessment tool is appropriate for children aged 3 years to 13 years
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Oucher
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What is the minimum age to use a numeric scale to rate pain?
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5 years
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What assessment tool is appropriate to use for non-communicating children aged 3-18 years?
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Non-communicating child's pain checklist
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How does the FLACC work?
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Pain is rated by the healthcare professional on a scale of 0-10 by assessing behaviors of the child in 5 categories.
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What does F stand for in FLACC?
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Face
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If a child scores a 0 for the F component of the FLACC assessment, what does this mean?
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They have a smile or no expression
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If a child scores a 1 for the F component of the FLACC assessment, what does this mean?
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They occasionally frown or grimace, may look withdrawn
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If a child scores a 2 for the F component of the FLACC assessment, what does this mean?
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They frequently or constantly frown, have a clenched jaw, or a quivering chin
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What does L stand for in FLACC?
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Legs
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If a child scores a 0 for the L component of the FLACC assessment, what does this mean?
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Relaxed or normal position
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If a child scores a 1 for the L component of the FLACC assessment, what does this mean?
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Uneasy, restless, tense
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If a child scores a 2 for the L component of the FLACC assessment, what does this mean?
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Kicking or legs drawn up
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What does the A stand for in FLACC?
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Activity
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If a child scores a 0 for the A component of the FLACC assessment, what does this mean?
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Lying quietly ,moves easily, normal position
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If a child scores a 1 for the A component of the FLACC assessment, what does this mean?
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Squirmy, shifting, tense
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If a child scores a 2 for the A component of the FLACC assessment, what does this mean?
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Arched, rigid, jerking
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What does the first C stand for in FLACC?
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Cry
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If a child scores a 0 for the first C component of the FLACC assessment, what does this mean?
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No cry
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If a child scores a 1 for the first C component of the FLACC assessment, what does this mean?
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Moans or whimpers, occasional complaints
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If a child scores a 2 for the first C component of the FLACC assessment, what does this mean?
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crying, screaming, sobbing, frequent complaints
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What does the second C in FLACC stand for?
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Consolability
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If a child scores a 0 for the second C component of the FLACC assessment, what does this mean?
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Content or relaxed
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If a child scores a 1 for the second C component of the FLACC assessment, what does this mean?
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Reassured by occasional touching or hugging, able to distract
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If a child scores a 2 for the second C component of the FLACC assessment, what does this mean?
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Difficult to console or comfort
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How is pain assessed with the FACES scale?
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Child is shown 6 faces of varying degrees of pain; Provider explains each face to the child and asks them to choose a face that best describes how they are feeling; Pain is rated by the child on a scale of 0-5; provider translates that score into 0, 2, 4, 6, 8, or 10
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What does a 0 indicate on the faces scale?
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no hurt
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What does a 1 indicate on the faces scale?
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Hurts a little bit
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What does a 2 indicate on the faces scale?
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Hurts a little more
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What does a 3 indicate on the faces scale?
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Hurts even more
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What does a 4 indicate on the faces scale?
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Hurts a whole lot
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What does a 5 indicate on the faces scale?
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Hurts worst
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Which assessment tool has the same premise as FACES?
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oucher
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Should a parent or caregiver be included in rating a childs pain?
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Yes
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While using the non-communicating child's pain checklist, how long should the provider observe the childs behaviors for?
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1o minutes
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What are the six subcategories of behavior that a provider observes while using the non-communicating childs pain checklist?
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-Vocal -Social -Facial -Activity -Body and limbs -Psychological
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What does a score of 0 in each category of the non-communicating childs pain checklist indicate?
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child is not at all displaying the behaviors that indicate pain
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What does a score of 1 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain just a little bit
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What does a score of 2 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain fairly often
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What does a score of 3 in each category of the non-communicating childs pain checklist indicate?
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Child is displaying the behaviors that indicate pain very often
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What does an overall score of 6-10 on the non-communicating childs pain checklist indicate?
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Mild pain
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What does an overall score of >11 on the non-communicating childs pain checklist indicate?
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moderate to severe pain
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What factor is highest on the hierarchy of assessment strategies?
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Subjective report of pain
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What factor is second highest on the hierarchy of assessment strategies?
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Painfulness of procedure
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What factor is third highest on the hierarchy of assessment strategies?
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Parents perspective
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What factor is fourth on the hierarchy of assessment strategies?
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Behavioral cues
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What factor is fifth on the hierarchy of assessment strategies?
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Reason to suspect pain; relief with analgesics
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What factor is lowest on the hierarchy of assessment strategies?
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Contributing situational factors
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What does rubor mean?
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redness
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What does calor mean?
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heat
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What does tumor mean?
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swelling
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What does dolor mean?
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Pain
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What types of crying typically indicate pain?
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-High pitched -Tense -Harsh -Non-melodious -Short -Sharp -Loud
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What does a bulge between the eyes and vertical furrows indicate?
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Pain in an infant
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What do raised cheeks indicate in an infant?
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Pain
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What does a broadened and bulging nose in an infant indicate?
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Pain
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What are the four major categories of drugs given to children for pain?
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-Opiods -Non-opiods -Anesthetics -Adjuvants/ co-analgesics
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What are the 5 major non-opiods given to children?
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-Acetaminophen -Aspirin -NSAIDS: Ibuprofen, Cox 2 inhibitors, ketoralac (Toradol)
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What are the 7 major opiods given to children?
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-Fentanyl -Morpine -Hydromorphone -Methadone -Codeine -Hydrocodone -Oxycodone
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Should acetaminophen be given for post operative pain?
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No
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Should acetaminophen be given for a migraine?
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No
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Should acetaminophen be given for vaccination prophylaxis?
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No
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What are the two appropriate routes to administer acetaminophen?
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PO or IV
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What is the appropriate dosage of acetaminophen for a child?
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10-15 mg/kg every 4-6 hours
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In 28-32 weeks gestation, what is the appropriate dosage interval for acetaminophen?
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8-12 hours
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What does the CRIES scale measure?
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C-Crying R-requires O2 for saturation >95 I- increased vital signs E-expression S-sleepless
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What does PIPP stand for?
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Premature infant pain profile
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What does NIPS stand for? What does it measure?
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Neonatal infant pain scale -Expression, cry, breathing, arm and leg movements, arousal state
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What does DSVNI stand for?
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Distress scale for ventilated newborn infants
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List the 4 major multidimensional infant pain scales.
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-CRIES -PIPP -NIPS -DSVNI
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What do the multidimensional infant pain scales measure?
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-The intensity of pain-related distress and pain reactivity
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What are the multidimensional infant pain scales best used for?
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To assess procedural pain, rather than ongoing pain assessments
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What is the minimum age requirement for ibuprofen?
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6 months
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What is the appropriate dosage for ibuprofen for a child?
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4-10 mg/kg/dose every 6-8 hours
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Should ibuprofen be administered for vaccinaiton prophylaxis?
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No
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What is the only NSAID approved for pain by the FDA for children under the age of 12 years?
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Ibuprogen
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What should be given for mind to moderate pain?
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Tylenol, aspirin, NSAIDS
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What should be given for moderate to severe pain?
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Opiods
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Should codeine be administered for sickle cell crisis?
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No
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What is the minimum age requirement for codeine?
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2 years
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What is the maximum daily dose for codeine?
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3mg/kg
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What is the typical route and dosage for codeine?
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.5-1mg/kg/dose every 4 to 6 hours PRN
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What is the most prescribed opioid for children?
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Codeine
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What oral opioid causes the most nausea?
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Codeine
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What must happen for codeine to be relieve pain?
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It is a pro-drug: it must be metabolized to morphine to relieve pain
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Should morphine be given to treat post operative pain?
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Yes
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Should morphine be given to treat cancer pain?
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Yes
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Should morphine be given to treat chronic pain?
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Yes
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Should morphine be given to treat neuropathic pain?
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No
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Should morphine be given through a PCA?
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No
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Should morphine be given for sickle cell crisis?
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No
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Should morphine be given to premature infants?
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No
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What is the gold standard for opioid analgesics?
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Morphine
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What is the maximum morphine dose?
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-Use second dose every hour if needed with good pain relief and minimal sedation -Maximum dose is the one that results in intolerable side effects
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How can morphine be given?
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PO, IV, IM, SQ
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What is the typical dosage of morphine when used IM, IV, or SC?
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.1-.2 mg/kg q2-4 hr
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What is the maximum dose of morphine when given IM IV or SC?
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15mg/dose or 05-.1 mg/kg
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What is the typical continuous IV infusion rate of morphine for postoperative pain in children 1-15 years?
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.02 mg/kg/hr
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What is the typical dosage of morphine when administered PO?
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.2-5 mg/kg/dose Q4-6 hrs PRN
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What is the minimum age requirement for fentanyl?
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2 years
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Under what circumstances should the oral transmucosal form of fentanyl be administered?
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For procedural pain
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What are the three routes that fentanyl should be given to treat post operative pain?
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-Epidural -PCA -Continuous infusion
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What is the dosage of fentanyl for continuous infusion in a neonate?
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1mcg/lg IVP
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What is the dosage of fentanyl for continuous infusion in a ventilated neonate?
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2-5mcg/kg/hr
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Which form of fentanyl oral transmucosal is appropriate for children over 2 years of age: oralet or actiq?
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Oralet
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Should meperidine be given for migranes?
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No
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Should meperidine be given for sickle cell crisis?
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No
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Should meperidine be given for chronic pain?
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Yes
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Should meperidine be given through a PCA?
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Yes
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What should meperidine (demerol) be reserved for?
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For very brief courses in patients who have a demonstrated allergy or intolerance to other opiods
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What is the toxic metabolite of meperidine? What can it cause?
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Normeperidine- a cerebral irritant and accumumulation can lead to seizures in otherwise healthy persons
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Should ketorolac be administered for fracture reduction pain?
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no
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Should ketorolac be administered for narcotic sparing effect?
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No
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Should ketorolac be administered for headache?
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No
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What is the minimum age requirement for ketorolac?
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16 years
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What is the typical dosage of ketorolac?
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.5mg/kg IV q 6 hrs for 48 to 72 hours with analgesics for moderate to severe pain
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Is methadone approved for use in children?
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No
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What is the typical dosage of methadone?
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.2mg/kg q 6 hrs
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What is the dosage of oral methadone for continuous pain, as seen in trauma?
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.3-.4 mg/kg/day divided into several doses
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Is hydromorphone approved for use in children?
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No
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Should hydromorphone be used for analgesia?
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No
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What is the typical dosage of hydromorphone for children?
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.05-.1mg/kg/dose PO q hr
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What is the typical dosage of hydromorphone for adolescents?
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1-2mg/dose IV q 4-6 hrs
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Is hydrocodone approved for children?
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No
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Should oxycodone be used for postoperative pain?
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No
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Should oxycodone be used for back pain?
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No
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Should oxycodone be used for dental pain?
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No
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Should oxycodone be used for neuropathic pain?
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No
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Is oxycodone approved for use in children?
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No
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What is the typical oxycodone dosage?
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.05-.15 mg/kg, up to 5mg per dose, q 4-6 hr
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Opioid side effects are often related to what?
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Dose
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Does tolerance to opioid side effects occur?
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Yes, except to constipation
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What are the frequent side effects of opioids?
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-N, V, C -Sedation -Mental clouding -Pruritis
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What are the less frequent side effects of opioids?
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-Myoclonus (jerky contractions) -Urinary retention -Delerium
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What are the adverse effects of opioids?
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Respiratory depression, cardiovascular collapse, addiction
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What respiratory rate in children qualifies as respiratory depression?
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<12 bpm
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How often should vital signs be checked during a painful procedure?
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q 15 minutes
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What should be assessed after a procedure involving sedation or analgesia?
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-CV and respiratory function -Arousability -Hydration -Protect from injury
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What percentage of individuals treated for pain become addicted to opioids?
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<1%
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What percentage of the american population is currently addicted to drugs?
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6-15%
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From 1992 to 2001, what happened to the treatment admission rate for opioid addiction?
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Doubled
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From 1992 to 2001, that happened to the emergency room visits related to opioid abuse?
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Increased by 117%
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What are the appropriate routes to give opioids to children? which of these should be avoided if possible?
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IM IV Oral; avoid IM
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Should pain medications be given routinely or PRN?
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Routinely to manage pain that is expected to last for an extended period of time
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Should children <18 years old receive intranasal medications?
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No
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Why should rectal administration of drugs be avoided in children, if possible?
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Absorption rates vary and kids dislike them
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Where should painful procedures take place?
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-In treatment room -Away from safe places like bed
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When should IV medications be given?
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For severe pain of sudden onset
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When should oral pain medications be administered?
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As soon as the patient can tolerate oral intake
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Why are oral pain medications preferred?
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They have a longer duration of analgesia than parenteral route; decreases peaks and valleys of pain and pain releif
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What does PRN stand for?
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Pro Re Nata (as necessary)
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What patients are at greatest risk for opioid related respiratory depression?
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Smallest
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Which patients should be started on 1/4 to 1/2 of the initial recommendations of pain medication and titrated up as needed?
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<6 months <10 kg History of apnea
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What dosage of medication should a child >50kg receive?
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Adult dosage: DO NOT calculate mg/kg
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Do opioids have an analgesic ceiling?
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No
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What is the pattern for respiratory depression from opioids?
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-Decreased LOC -Decreased depth of respiration -Decreased RR -Decreased O2 sat
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How long does it typically take oral medications to reach peak analgesic effects?
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1-2 hrs
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What topical medication contains lidocaine and prilocaine in the form of a cream or disk?
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ELMA
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When should ELMA be applied for a superficial procedure such as IV insertion or biopsy?
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60 mins before
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When should ELMA be applied for a deep puncture?
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2.5 hrs before
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What type of dressing should be applied over ELMA?
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Occlusive
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Prior to the procedure, what should the nurse do with ELMA?
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Clean the skin and check for adequate response, demonstrate to child that skin is not sensitive by lightly scratching or tapping
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What indicates an adequate response to ELMA?
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Redened, blanched skin
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What are the advantages of using a PCA?
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-Adjusts for individual variation in kinetics and dynamics -Gives a sense of control -Avoids bargain and begging -Safe and effective
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What are the disadvantages of using a PCA?
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-Expense ($88/day) -Anyone can push the button -Push the button or suffer -May not completely relieve pain -Not a panacea: side effects still persist
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What is the minimum age for a PCA?
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7 years
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What are the requirements for a PCA?
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-Able to push button -Able to quantify pain -Unable to tolerate oral analgesics -Understand the relationship between pushing the button and medication delivery -Understand the safety mechanisms of the machine -Report unsatisfactory pain relief
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What is the major advantage of using epidural analgesia?
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Provides good to excellent analgesia with less side effects than with the use of systemic opioids: -Infrequent nausea -Minimal sedation -Earlier ambulation -Retention of cough reflex -Decreased pulmonary dysfunction -Decreased neuroendocrine and metabolic response to surgical stress
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What are the disadvantages of epidurals?
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-Expense and availability -Parents and caregivers often feel that if the child is not receiving adequate relief of pain from the epidural medication there is noting more that can be done; child and family may not report pain that is not completely relieved -Infrequent use has led to misconceptions and fear with use
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Epidural use is appropriate for which types of patients?
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-Open heart surgery -Abdominal procedures -Anal or urogenital procedures -Orthopedic surgeries of the lower limbs -Thoracic surgeries -Cancer pain -Pancreatitits
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For which patients is epidural contraindicated?
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-Vertebral anomalies that would make catheter placement difficult -Coagulopathies that may make the child at an increased risk for epidural hematomas -Systemic infections
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If a child receiving an epidural has a temperature spikes, why must the physician be notified?
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The epidural catheter in a child with an active systemic infection can be a conduit to the CSF- and a meningitis may result
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What nonpharmacological measures can be taken to decrease pain?
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-Distraction (play, joke, radio, movies, computer games, telling stories) -Relaxation (holding, breathing) -Guided imagery -Positive self talk -Behavioral contracting with rewards -Containment -Nonutritive sucking -Kangaroo care -COmplemetnary and alternative medicine -Massage -Chiropractic options -Heat/cold -Aromatherapy -Hypnosis -TENS units
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List topical anesthetics appropriate for use with children.
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-EMLA -Pain ease (vapocoolant) -Numby stuff -Lidosite -LMX4 -Synera -J tip
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Explain the gate control theory.
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-Inhibitory neuron stimulation reduces pain sensation -Distractions and stimulations can enhance effects of analgesics
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What position should an infant be held in to give an oral medication?
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Semi-reclining
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What position should a small child be held in to give an oral medication to prevent aspiration?
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Upright
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How should liquid oral medications be administered to children?
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In side of mouth in small amounts to allow swallowing
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If a child does not like the taste of an oral medication, what should the nurse instruct them to do?
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Hold their nose
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What can a nurse do to promote swallowing of oral medication in an infant?
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Stroke under chin and hold cheeks together
