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Pain Assessment CHAPTER

42
and Management
in Children

Felicia must be in pain so soon after her surgery. I know I would have pain
if it were me. Can she get pain medicine without getting another needle?
Mother of Felicia, 5

LEARNING OBJECTIVES
Describe the physiologic and behavioral
consequences of pain in children.
Select an appropriate tool to assess the pain of
infants and children in each age group.
Describe the nursing assessment and management
for a child receiving an opioid analgesic.
Explain the rationale for the effectiveness of
nonpharmacologic (complementary) methods of
pain control.
Assess children of different ages with acute pain
and develop a nursing care plan that integrates
pharmacologic interventions and
developmentally appropriate nonpharmacologic
(complementary) therapies.
Develop a nursing care plan for assessing and
monitoring the child having sedation and analgesia
for a medical procedure.

MEDIALINK www.prenhall.com/london

CD-ROM Companion Website

NCLEX-RN Review NCLEX-RN Review
Animation: Morphine Case Study
Videos: Thinking Critically
Pain Management Kit MediaLink Applications:
Pain Perception Managing Light Sedation
Nursing in Action: Administering Patient-Controlled Calculating Opioid Dosage
Analgesia Postoperative Pain Assessment
Nursing in Action: Sedation Monitoring Complementary Care: Hypnotherapy for Children
Postoperative Pain Flow Chart
Audio Glossary
Skill 13-1 Selected Pediatric Pain Scales
Skill 13-2 Patient-Controlled Analgesia
Skill 13-3 Monitoring Sedation
Skill 13-4 Local Pain Blocks
1207
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E
veryone has his or her own perception of pain. A neurologic response
KEY TERMS to tissue injury, pain is an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage (see Patho-
Acute pain, 1208 physiology Illustrated). Effective pain management is every childs right.
Anxiolysis, 1227
Chronic pain, 1208
ACUTE AND CHRONIC PAIN
Deep sedation, 1227
Distraction, 1224 Pain exists when the patient says it does (McCaffrey & Pasero, 1999). Pain
may be either acute or chronic. Acute pain is sudden and of short duration;
Electroanalgesia, 1225
it may be associated with a single event, such as surgery, or an acute exacer-
Equianalgesic dose, 1216
bation of a condition such as a sickle cell crisis. The inflammatory response
Light sedation, 1227 that follows the initial tissue injury causes a sustained pain response (Fuller,
Nonsteroidal anti-inflammatory drugs 2001). Chronic pain is a persistent pattern of pain, lasting longer than 6
JCAHO

(NSAIDs), 1215 months; it is generally associated with a prolonged disease process such as
Opioids, 1215 juvenile rheumatoid arthritis.
Pain, 1208 In 2001 the Joint Commission on Accreditation of Healthcare Organi-
zations introduced standards for the assessment and management of pain in
MEDIALINK

Patient-controlled analgesia
(PCA), 1219 patients. All patients are assessed for pain, and they have the right to appro-
Tolerance, 1223 priate pain management. Patient education includes managing pain as a part
of treatment.
Withdrawal, 1217

MISCONCEPTIONS ABOUT PAIN IN CHILDREN

Healthcare professionals once believed that children feel less pain than
adults. Undertreatment of pain was based on these attitudes about pain, the
difficulty and complexity of pain assessment in children, and inadequate re-
search. Some nurses still undertreat pain, either not giving pain medication
on a fixed schedule around the clock as ordered by the physician or giving
less than 40% of the pain medication ordered (Vincent, 2001). For a review
of past myths and the contrasting reality, see Table 421.
Research has shown that past beliefs about childrens perception of pain
were incorrect. Even newborns feel pain. All the necessary peripheral and
central nervous system anatomic structures and functional ability to process
pain are present by 20 weeks gestation (Pasero, 2002). Pain impulses are
transmitted along the nonmyelinated C fibers, and the pain signal is less pre-
cise. Pain conduction may be slower in newborns, but the distance the pain
stimuli must travel is much shorter than in adults. Because the descending
neurotransmitters are less developed, newborns are less able to reduce the
pain impulses. Premature and newborn infants may be even more sensitive
to pain than older children. Newborns and infants also remember pain. By 6
months of age, children demonstrate anticipatory fear of pain when taken to
a location where they once experienced pain (McGrath & Craig, 1989).

DEVELOPING CULTURAL COMPETENCE

HEALTH PROFESSIONALS ATTITUDES
ABOUT CHILDRENS PAIN
Think about your personal pain experiences during childhood and how your family members
encouraged you to be stoic or to express pain. These types of experiences often contribute
to a health professionals attitudes about pain experienced by children. For example, health-
care workers may believe that being in pain for a little while is not so bad or that pain helps
build character.
1208
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Pain Assessment and Management in Children 1209

Pain Perception
Nociceptors (free nerve endings at the site of tissue damage)
transmit information by specialized nerve fibers to the spinal
cord. Unmyelinated C fibers slowly transmit dull, burning, dif-
fuse pain as well as chronic pain. Large, myelinated A-delta Pain
perception point
fibers quickly transmit sharp, well-localized pain. Nociceptors
are stimulated by mechanical, thermal, and chemical injury.
5
Biochemical mediators (bradykinin, prostaglandin, leukotri- 3 Dorsal horn; location of
enes, serotonin, histamine, catecholamines, and substance P) Substantia gelatinosa
are produced in response to tissue damage. These substances (pain signal modified)
help move the pain impulse from the nerve endings to the Spinal ganglia 4
spinal cord. After the sensory information reaches the substan- A-delta fibers
tia gelatinosa in the dorsal horn of the spinal cord, the pain sig- (fast transmission of
nal may be modified depending on the presence of other sharp, localized pain)
stimuli, from either the brain or the periphery. The pain signal is 1 Nociceptors
then transmitted to the brain through the spinothalamic, retic- (pain
ulospinal, and spinomesoencephalic nerve pathways, where receptors) 2
perception occurs. Once the sensation reaches the brain, emo- C fibers
(slow transmission
tional responses may increase or decrease the intensity of the of dull, burning, chronic
pain perceived. pain)
Lateral
The gate control theory of pain helps explain how the pain
spinothalamic tract
impulses are allowed to proceed to the brain. The substantia
gelatinosa serves as a gate and regulates the transmission of
pain and other impulses to the brain (Huether & Leo, 2002).
Since pain and nonpain impulses are sent along the same
pathways, nonpain impulses can compete with pain impulses
for transmission.

CLINICAL MANIFESTATIONS Facial grimacing, biting or pursing lips; see

Physiologic Indicators
Acute pain stimulates the adrenergic nervous system and
results in physiologic changes, including tachycardia,
tachypnea, hypertension, pupil dilation, pallor, increased
perspiration, and increased secretion of catecholamines
and adrenocorticoid hormones. Changes in these signs
demonstrate a complex stress response. These signs are not
specific to pain, so they cannot be used for monitoring pain.
Chronic pain of long duration permits physiologic
adaptation, so normal heart rate, respiratory rate, and
blood pressure levels are often seen (Huether & Leo, 2002).
Behavioral Indicators
Children in acute pain behave in many of the same ways as
children who show signs of fear and anxiety (Hazinski,
1999; Tesler, Holzemer, & Spreker, 1999). These behaviors
include the following:
Short attention span (child is difficult to distract)
Irritability (child is difficult to comfort)
Figure 421 on p. 1211 for facial expression of
newborns and infants
Posturing (guarding a painful joint by avoiding
movement), remaining immobile, or protecting the
painful area
Drawing up knees, flexing limbs, massaging affected area
Lethargy, remaining quiet, or withdrawal
Sleep disturbances
Preverbal children may show conflicting signs of pain
(restlessness, agitation or withdrawal, hyperalert or vigi-
lant, grimacing, crying, or anger), making pain assessment
and management more challenging.
Children often suffer additional emotional distress and
fear that the discomfort will worsen. Depression and aggres-
sive behavior are frequently overlooked as indicators of pain.
CONSEQUENCES OF PAIN
Unrelieved pain is stressful and has many undesirable
physiologic consequences (Table 422). For example, the
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1210 CHAPTER 42
TABLE 421 Misconceptions about Pain in Infants and Children
Myth
Newborns and infants are incapable of feeling pain. Children do not
feel pain with the same intensity as adults because a childs nervous
system is immature.
Infants are incapable of expressing pain.
Infants and children have no memory of pain.
Parents exaggerate or aggravate their childs pain.
Children are not in pain if they can be distracted or if they are
sleeping.
Repeated experience with pain teaches the child to be more tolerant
of pain and cope with it better.
Children tolerate discomfort well. They become accustomed to pain
after having it for a while.
Children recover more quickly than adults from painful experiences
such as surgery.
Children tell you if they are in pain. They do not need medication
unless they appear to be in pain.
Children without obvious physical reasons for pain are not likely to
have pain.
Children run the risk of becoming addicted to pain medication when
used for pain management.
child with acute postoperative pain takes shallow breaths
and suppresses coughing to avoid more pain. These self-
protective actions increase the potential for respiratory
complications. Unrelieved pain may also delay the return
of normal gastric and bowel functions and cause a stress
ulcer. Anorexia associated with pain may delay the healing
process. The long-term effects of pain on the childs physi-
cal or psychologic condition are unknown.
PAIN ASSESSMENT
The goal of pain assessment is to provide accurate informa-
tion about the location and intensity of pain and its effects on
the childs functioning. No laboratory tests are routinely used
to assess pain. Prolonged, severe pain produces a physiologic
stress response that includes the chemical release of cate-
cholamines, cortisol, aldosterone, and other corticosteroids.
Reality
By 20 weeks gestation, a fetus has most of the anatomic and
functional requirements for pain processing. Term infants have the
same level of sensitivity to pain as older infants and children. Preterm
infants may actually have greater sensitivity.
Infants express pain with both behavioral and physiologic cues that
can be assessed.
Preterm infants have been noticed to associate the smell of alcohol
with heel sticks and to try to pull the foot away to avoid the pain.
Infants cry in anticipation of immunizations.
Parents know their child and are able to identify when the child is in
pain.
Children use distraction to cope with pain, but they soon become
exhausted when coping with pain and fall asleep.
Children who have more experience with pain respond more vigorously
to pain. Experience with pain teaches how severe the pain can
become.
Children do not tolerate pain any better than adults, and may have less
tolerance with prior painful experiences. They do not become
accustomed to pain or cope with it better than adults.
Children heal quickly from surgery, but they have the same amount of
pain from surgery as an adult.
Children may be too young to express pain or afraid to tell anyone
other than a parent about the pain. The child fears the treatment for
pain may be worse than the pain itself.
The cause of pain cannot always be determined. The feeling of pain is
subjective and should be accepted by nurses.
Addiction is extremely rare when the child is treated for an acute
condition.
Insulin secretion also decreases, leading to increased amounts
of glucose and severe hyperglycemia (Hazinski, 1999).
PAIN HISTORY
Parents can provide a great deal of information about the
childs response to pain, such as the following:
How the child typically expresses pain, both verbally
and behaviorally. Children and parents use similar
terms to describe pain. Some examples of words used
are a hurt, owie, boo-boo, stinging, sore, cutting, burning,
itching, hot, and tight. Knowing the appropriate word
to use makes communicating with the child easier. The
parent can often provide signs used to recognize the
childs pain.
The childs previous experiences with painful
situations and reactions.
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Pain Assessment and Management in Children 1211

FIGURE 421
THINKING CRITICALLY

Bulged brows
DETERMINING WHEN A CHILD IS IN PAIN
Felicia, who is 5 years old, was struck by a car. Six hours ago, she had
surgery to repair a liver laceration, but she also has numerous bruises
Brows lowered,
drawn together and abrasions on her body. After spending 3 hours in the postanes-
thesia unit, she was moved to the pediatric inpatient unit. She has an
Eyes squeezed shut intravenous line in place, as well as a nasogastric tube attached to low
suction. Her abdominal dressing is clean and dry. Felicia has orders for
Furrowed nasolabial morphine IV every 3 hours around the clock for the first 24 hours.
creases Felicias mother is rooming in with her during her hospital stay.
Taut tongue
Twelve hours after surgery, Felicia is dozing but is responsive to verbal
stimuli. Her most recent IV morphine was given 2 hours ago.The nurse
Open, angular, squarish attempts to determine how well Felicias pain is managed. Her facial
lips and mouth expression indicates that she is not in pain. Felicias mother feels that
Quivering chin she is resting fairly comfortably.
How do you know whether Felicia is in pain? Can you expect her
to tell you if she feels pain? Is any additional assessment needed to
Neonatal characteristic facial responses to pain include bulged brow, eyes
justify giving Felicia more pain medication? What other pain relief mea-
squeezed shut, furrowed nasolabial creases, open lips, pursed lips,
stretched mouth, taut tongue, and a quivering chin. sures could reduce or help to control her pain in the first 24 hours?
Adapted from Carlson, K. L., Clement, B. A., & Nash, P. (1996). Neonatal pain: From concept to re-
What is the appropriate dose of IV morphine for Felicia, who
search questions and the role of the advanced practice nurse. Journal of Perinatal Neonatal Nursing, weighs 25 kg? What is the timing of assessments of response to pain
10 (1), 6471. and potential side effects? What signs of respiratory distress indicate
a need for naloxone administration?

How the child copes with and manages pain. The child
with several past pain experiences may not exhibit the What works best to reduce the childs pain?
same types of stressful behaviors as the child with few The parents and childs preferences for analgesic use
pain experiences. and other pain interventions.

TABLE 422 Physiologic Consequences of Unrelieved Pain in Children

Responses to Pain Potential Physiologic Consequences

Respiratory Changes
Rapid shallow breathing Alkalosis
Inadequate lung expansion Decreased oxygen saturation, atelectasis
Inadequate cough Retention of secretions

Neurologic Changes
Increased sympathetic nervous system activity Tachycardia, change in sleep patterns, increased blood glucose and
cortisol levels

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

Immune System Changes

Depression of immune response Increased risk of infection

Gastrointestinal Changes
Increased intestinal secretions and smooth muscle sphincter tone Impaired gastrointestinal functioning, ileus
Data from Eland, J. M. (1990). Pain in children. Nursing Clinics of North America, 25, 871884; Altimier, L., Norwood, S., Dick, M. J., et al. (1994). Postoperative pain management in
preverbal children: The prescription and administration of analgesia with and without caudal analgesia. Journal of Pediatric Nursing, 9(4), 226232; McCaffrey, M., & Pasero, C.
(1999). Pain: Clinical manual (2nd ed., p. 24, 27). St. Louis, MO: Mosby; and Mitchell, A., & Boss, B. J. (2002). Adverse effects of pain on the central nervous systems of newborns
and young children: A review of the literature. Journal of Neuroscience Nursing, 34(5), 228236.
lon23944_ch42.qxd 2/17/06 8:53 AM Page 1212
1212 CHAPTER 42
DEVELOPING CULTURAL
COMPETENCE
TERMS THAT DESCRIBE PAIN INTENSITY
The terms pain, hurt, and ache have been found to describe pain
intensity across cultures. Pain is most intense, hurt is less severe, and
ache is least severe (Gaston-Johansson, Albert, Fagan et al., 1990).
Similarly, pain and hurt mean greater pain than ache in school-age
children and adolescents (LaFleur & Raway, 1999). The term tender
or tenderness may be confusing for some families in which English is
a second language. Tender or tenderness is more commonly associ-
ated with caring or romance or with meat rather than soreness or
pain.
Older children may be able to give a history of painful
procedures. When attempting to obtain information about
the childs pain experiences and present level of pain, keep
in mind that many children modify their pain descriptions
depending on the type of questions asked and what they
expect will happen as a result of their response. Examples
of questions to ask include the following:
What kinds of things caused hurt in the past and what
made it feel better?
Does the child tell others about being in pain and what
does the child want others to do for the pain?
What does the child not want done when he or she is
hurting? What would the child like the nurse to do
for the hurt?
Where is the hurt, and what does it feel like? What
could be causing the hurting?
CULTURAL INFLUENCES ON PAIN
Childrens culture and social learning have a tremendous
influence on their expression of pain. Cultural traditions
often guide children about self-control, coping, and enlist-
ing the assistance of others (Huether & Leo, 2002). Chil-
dren learn directly and indirectly from their parents about
how to respond to pain. By showing approval and disap-
proval, parents teach their children how to behave when in
pain. This instruction includes the following:
How much discomfort justifies a complaint
How to express the complaint
How and when to stop complaining
Whom to approach for pain relief
For example, boys in the United States are usually encour-
aged to hide their pain by acting brave and not crying. Girls
are often encouraged to express their pain openly. Children
also observe other family members in pain and imitate
their responses (Abu-Saad, 1984).
DEVELOPING CULTURAL
COMPETENCE
EXPRESSION OF PAIN
Some ethnic groups, such as Asian,Anglo-SaxonGermanic, and Irish,
do not openly express pain. People of Italian and Jewish descent are
more likely to use both verbal and nonverbal methods to express pain
freely. However, children have individualized responses, and younger
children have had less time to acquire culturally learned behaviors.
DEVELOPMENTAL RESPONSES TO PAIN
A childs responses to and understanding of pain depend on
the childs age and stage of development. See Tables 423
and 424 to learn more about the childs responses at each
age.A childs responses to pain also depend upon situational
factors that influence pain responses (McGrath, 1995):
Cognitiveunderstanding of the pain source, ability to
control what will happen, focus of attention is on the
pain or a distraction
Behavioraluse of a pain control strategy, ability to
continue usual activities, response of parents and
healthcare providers
Emotionalpresence of fear, anxiety, frustration,
anger, depression
Young children are unable to give a detailed description of
their pain because of their limited vocabulary and pain
experiences. Depending on their developmental stage, chil-
dren use different coping strategies, such as escape, post-
ponement or avoidance, diversion, and imagery, to deal
with pain. Healthcare providers now recognize that chil-
dren do not complain of pain for several reasons:
Some children believe they need to be brave.
Preschoolers and adolescents may assume the nurse
knows they have pain.
Some children are afraid that an injection to relieve
pain will hurt more than the pain they have.
GROWTH AND DEVELOPMENT
School-age children and adolescents may not exhibit distress in direct
proportion to their pain intensity. Thus, behavioral measures may not
match the childs self-report of pain intensity. Older children often ap-
pear calm, are expressionless, and limit movement following surgery,
but report pain of moderate to severe levels (Tesler et al., 1999). Be-
cause children in these age groups can accurately report pain inten-
sity, use the self-report of pain as a valid pain assessment.
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Pain Assessment and Management in Children 1213

TABLE 423 Behavioral Responses and Verbal Descriptions of Pain by Children

of Different Developmental Stages

Age Group Behavioral Response Verbal Description

Infants

6 months Generalized body movements, chin quivering, facial Cries
grimacing, poor feeding
612 months Reflex withdrawal to stimulus, facial grimacing, disturbed Cries
sleep, irritability, restlessness

Toddlers
13 years Localized withdrawal, resistance of entire body, aggressive Cries and screams, cannot describe intensity or type of
behavior, disturbed sleep pain

Preschoolers
36 years Active physical resistance, directed aggressive behavior, Can identify location and intensity of pain, denies pain,
(preoperational) strikes out physically and verbally when hurt, low may believe his or her pain is obvious to others
frustration level

School-Age Children
79 years Passive resistance, clenches fists, holds body rigidly still, Can specify location and intensity of pain and describe
(concrete operations) suffers emotional withdrawal, engages in plea bargaining its physical characteristics in relation to body parts
1012 years May pretend comfort to project bravery, may regress with Able to describe intensity and location with more
(transitional) stress and anxiety characteristics, able to describe psychologic pain

Adolescents
1318 years Want to behave in a socially acceptable manner (like More sophisticated descriptions as experience is gained;
(formal operations) adults), show a controlled behavioral response may think nurses are in tune with their thoughts, so they
dont need to tell the nurse about their pain

PAIN ASSESSMENT SCALES pain (Manworren & Hynan, 2003; Willis, Merkel, Voepel-

Various pain scales are used to assess pain in children.
Nonverbal Children
Physical and behavioral indicators are used to quantify pain
in nonverbal children. For example, the Neonatal Infant Pain
MEDIALINK
Lewis, et al., 2003). See Table 426 on p. 1215.
Young children (3 years and older) can localize pain if
given an outline of the front and back of the body. The
child can mark where the pain is located or color the area
of pain with crayons. The child should use one color for the

Skill 13-1: Selected Pediatric Pain Scales

Scale (NIPS) and the FLACC Behavioral Pain Assessment
Scale rely on the nurses observation of the childs behavior.
The NIPS is designed to measure procedural pain in
preterm and full-term newborns up to 6 weeks after birth.
The newborn facial expression, cry quality, breathing pat-
terns, arm and leg position, and state of arousal are ob-
served. This tool has high inter-rater reliability and validity.
See Table 425 on p. 1215.
The FLACC is designed to measure acute pain in in-
fants and young children following surgery, and it can be
used until the child is able to self-report pain with another
pain scale. FLACC is an acronym for the five categories that
are assessed: Face, Legs, Activity, Cry, and Consolability. To
use FLACC the nurse observes the child during routine
care for 1 to 5 minutes, and then selects the score that most
closely matches each behavior noted. The scores for the five
categories are added together for the total score. The tool
has validity and reliability for evaluation of postoperative
place where it hurts the most, and another color for areas
with less pain.
Self-Report Pain Scales
Other scales depend on the childs self-report of pain in-
tensity (see Skill 131). SKILLS To use pain scales, the child
must be developmentally ready and understand the con-
cept of a little or a lot of pain well enough to tell the nurse.
Children 2 to 3 years of age are usually able to understand
the concept of more or less. This child cannot be given
more than three choices on a pain scale (none, some, a lot)
when assessing pain. When the child can understand rank
order and is able to classify, match, and estimate, a numeric
scale can be used. A child who correctly responds to either
of the following items is developmentally ready for a nu-
meric scale (Merkel, 2002):
Which number is larger, 5 or 9? Which number is
smaller, 7 or 4?
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1214 CHAPTER 42

TABLE 424 Childrens Understanding of Pain by Developmental Stage

Developmental Stage Understanding of Pain

Infants
< 6 months No apparent understanding of pain; newborns exposed to repeated painful experiences in ICU demonstrate
memory of pain by holding their breath when approached by care providers
612 months Anticipate a painful event such as an immunization with fear; responsive to parental anxiety

Toddlers
13 years Do not understand what causes pain and why they might have pain; demonstrate fear of painful situations; use
common words for pain such as owie and boo-boo

Preschoolers
36 years Pain is a hurt; have language skills to express pain, and skills increase with age; do not relate pain to illness but
(preoperational) may relate pain to an injury; often believe pain is punishment; do not understand why a painful procedure will
make them feel better or why an injection takes pain away

School-Age Children
79 years Can understand simple relationships between pain and disease but have no clear understanding of the cause of
(concrete operations) pain; can understand the need for painful procedures to monitor or treat disease; may associate pain with feeling
bad or angry; may recognize psychologic pain related to grief and hurt feelings
1012 years Better able to understand the relationship between an event and pain; have a more complex awareness of
(transitional) physical and psychologic pain, such as moral dilemmas and mental pain

Adolescents
1318 years Have a sophisticated understanding of the causes of physical and mental pain; relate to the pain experienced
(formal operations) by others; pain has both qualitative and quantitative characteristics

Ask the child to place several blocks or pieces of paper
of different sizes in a row from biggest to smallest.
Examples of self-report pain scales include the Faces Pain
Oucher Scale
used to assess their pain. The nurse should ask the child to
describe the pain and give its location. At about 8 years of
age, children can give a separate rating for the intensity of
pain and describe how unpleasant it is (Jedlinksy, Mc-

Scale and the Oucher Scale. The Oucher Scale presents a se-
ries of six photographs of a child expressing increased inten-
sity of pain in combination with a vertical Visual Analog Scale
(Figure 422 on p. 1216). The child selects a face that best
fits his or her level of pain; an older child can select a number
between 0 and 10. The nurse should not compare the photos
MEDIALINK
Carthy, & Michel, 1999). Providing some words such as
sharp, dull, aching, pounding, cold, hot, burning, throb-
bing, stinging, tingling, or cutting can help children de-
scribe their pain.
The Numeric Pain Scale or Visual Analog Scale is a sin-
gle 10-cm horizontal or vertical line that has descriptors of

with the childs facial expression to determine pain level. The
tool has been developed for three cultural groups with valid-
ity and reliability for children between 3 and 12 years of age.
The Faces Pain Rating Scale has a series of six cartoon-
like faces with expressions from smiling to tearful that can be
used by children starting at 3 years of age (Figure 423 ).
The nurse explains the meaning of each face and asks the
child to select the face that is the closest match to the pain felt.
As with the Oucher Scale, the nurse should not compare the
faces with the childs facial expression to determine pain
level. Comparison of faces pain scales has revealed that those
scales with a smiling face as the indicator of no pain resulted
in significantly higher pain ratings by children and parents
than scales using a neutral expression face as an indicator of
no pain (Chambers, Gresbrecht, Craig et al., 1999).
School-age children and adolescents have better num-
ber concepts and language skills, so additional tools can be
pain at each end (no pain, worst possible pain). Marks and
numbers are placed at each cm on the line.
The Poker Chip Tool uses four checkers or poker chips
to quantify pain. The child is asked to pick the number of
chips that best match the pain felt, with one chip being a lit-
tle pain and four being the most pain he or she could have.
The Word-Graphic-Rating Scale has words describing
increasing pain intensity across a horizontal line. The child
marks the line that is closest to the level of pain felt. A mil-
limeter ruler can be used to quantify the pain and record
the pain score (Figure 424 on p. 1217).
The Adolescent Pediatric Pain Tool includes a human
figure drawing, the Word-Graphic Rating Scale, and a
choice of descriptive words. Adolescents indicate pain
sites on the human figure outline, use the Word-Graphic-
Rating Scale as described, and use the word choices to
characterize the pain felt.
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Pain Assessment and Management in Children 1215

TABLE 425 Neonatal Infant Pain Scale (NIPS)

Characteristic Scoring Criteria Characteristic Scoring Criteria

Facial Expression Arm Movements
0  Relaxed muscles Restful face with neutral expression 0  Relaxed/restrained Relaxed, no muscle rigidity,
1  Grimace Tight facial muscles; furrowed (with soft restraints) random movements of arms
brow, chin, and jaw (Note: At low 1  Flexed/extended Tense, straight arms; rigid; or rapid
gestational ages, infants may have extension and flexion
no facial expression) Leg Movements
Cry 0  Relaxed/restrained Relaxed, no muscle rigidity,
0  No cry Quiet, not crying (with soft restraints) occasional random movements
1  Whimper Mild moaning, intermittent cry 1  Flexed/extended of legs
2  Vigorous cry Loud screaming, rising, shrill, and Tense, straight legs; rigid; or rapid
continuous (Note: silent cry may extension and flexion
be scored if infant is intubated, State of Arousal
as indicated by obvious facial 0  Sleeping/awake Quiet, peaceful, sleeping; or alert
movements) 1  Fussy and settled
Breathing Patterns Alert and restless or thrashing; fussy
0  Relaxed Relaxed, usual breathing pattern
1  Change in breathing maintained
Change in drawing breath;
irregular, faster than usual,
gagging, or holding breath
Used with permission from Lawrence, J., Alcock, D., McGrath, D. P., et al. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 61.

CLINICAL THERAPY FOR PAIN PAIN MEDICATIONS

Pain management includes both drug and nondrug mea- Drug interventions include the use of opioids, nonsteroid-
sures. Children need adequate pain medication, but non- al anti-inflammatory drugs (NSAIDs), and nonnarcotic
drug measures can enhance pain management and analgesics (acetaminophen).
ultimately reduce the amount of pain medication needed.

TABLE 426 FLACC Behavioral Pain Assessment Scale

SCORING
Categories 0 1 2
Face No particular expression or smile Occasional grimace or frown; Frequent to constant frown, clenched jaw,
withdrawn, disinterested quivering chin

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

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

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

Consolability Content, relaxed Reassured by occasional touching, hugging, Difficult to console or comfort
or being talked to; distractable
Observe the child for 5 minutes or longer. Observe the legs and body uncovered. Reposition the patient or observe activity. Assess body for tenseness and tone. Initiate consoling
interventions if needed. Each of the five categories is scored from 0 to 2, resulting in a total score between 0 and 10. A total score of 0  relaxed and comfortable; 13  mild
discomfort; 46  moderate pain; 710  severe discomfort or pain.
Used with permission from Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring post-operative pain in young children.
Pediatric Nursing, 23(3), 293297.
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1216 CHAPTER 42

FIGURE 422

Use the Oucher Scale that is the best

match for the ethnicity of the child. Af-
ter determining that the child has an
understanding of number concepts,
teach the child to use the scale. Point
to each photo and explain that the
bottom picture is no hurt, the second
picture is a little hurt, the third picture
is a little more hurt, the fourth picture
is even more hurt, the fifth picture is
a lot of hurt, and the sixth picture is
the biggest or most hurt you could
ever have. The numbers beside the
photos can be used to score the
amount of pain the child reports.
The Caucasian version of the Oucher used with per-
mission from Judith E. Beyer, RN, PhD, 1983. The
African-American version of the Oucher used with
permission from Mary J. Denyes, RN, PhD, and An-
tonia M. Villarruel, RN, PhD, 1990. The Hispanic ver-
sion of the Oucher used with permission from
Antonia M. Villarruel, RN, PhD, 1990.

Opioids opioids by an oral route is as effective as by intramuscular

Opioids are commonly given for severe pain, such as after and intravenous routes when the drug is given in an
surgery or a severe injury. Opioids (e.g., morphine and equianalgesic dose (the amount of drug, whether given
codeine) may be administered by oral, subcutaneous, in- by oral or parenteral routes, needed to produce the same
tramuscular, and intravenous routes. Administration of analgesic effect) (Table 427). Oral and intravenous routes

FIGURE 423

0 1 2 3 4 5
No Hurt Hurts Hurts Hurts Hurts Hurts
Little Bit Little More Even More Whole Lot Worst
The Faces Pain Rating Scale is valid and reliable in helping children to report their level of pain. Make sure the child has an understanding of number
concepts and then teach the child to use the scale. Point to each face and use the words under the picture to describe the amount of pain the child
feels. Then ask the child to select the face that comes closest to the amount of pain felt.
Used with permission from Wong, D. L., & Baker, C. M. (1988). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14, 916.
lon23944_ch42.qxd 2/17/06 8:53 AM Page 1217

Pain Assessment and Management in Children 1217

FIGURE 424 are preferred for children. Rectal preparations of some

No Little Moderate Large
Pain Pain Pain Pain
Word-Graphic Rating Scale has words rather than numbers under the line.
It may be used by itself or with the Adolescent Pediatric Pain tool. Teach the
child to use the tool by pointing to the side of the line that is no pain. Then
run your finger along the line and tell the child that this location is the worst
possible pain. If the child has some pain, ask the child to make a mark
along the line that is the best match for the amount of pain felt. Use a mil-
limeter ruler to measure from the no pain end of the line to the marked
location to identify the pain score. Make sure the line is the same length
each time pain is assessed so comparisons can be made.
Used with permission from Sinkin-Feldman, L., Tesler, M., & Savedra, M. (1997). Word placement on
the Word-Graphic Rating Scale by pediatric patients. Pediatric Nursing, 23, 3134.
opioids are also available. The optimal analgesic dose
varies widely among patients in all age groups (American
Pain Society, 1999).
Worst
Possible Common side effects include sedation, nausea, vomit-
Pain ing, constipation, and itching. Potential complications of
opioids include respiratory depression, cardiovascular col-
lapse, and addiction. When the childs condition is unsta-
ble, as in trauma or critical illness, the dosage of opioids
must be carefully calculated to match the childs cardiores-
piratory status, although infants and children are no more
likely than adults to develop respiratory depression follow-
ing administration of a weight-specific dose of narcotics
(Holder & Patt, 1995). Addiction is a rare complication in
adults and children treated for painful conditions.
When giving opioids over an extended period of time,
children may experience withdrawal, the physical signs and
symptoms that occur when a sedative or pain drug is stopped
suddenly in a patient with physical dependence. An example
would be a child in an intensive care setting who experienced

TABLE 427 Opioid Analgesics and Recommended Doses for Children and Adolescents*

Approximate Approximate Recommended Starting Recommended Starting

Equianalgesic Equianalgesic Dose (Adults 50 kg) Dose (Children & Adults
50 kg)
Drug Oral Dose Parenteral Dose Oral Parenteral Oral Parenteral
Morphine 30 mg 10 mg 1530 mg 10 mg 0.3 mg/kg 0.1 mg/kg
every 34 hr every 34 hr every 34 hr every 34 hr

Codeine 130 mg 75 mg IM or 3060 mg 60 mg 0.51 mg

Subcutaneous every 34 hr every 2 hr every 34 hra NR

Hydromorphone 7.5 mg 1.5 mg 48 mg 1.5 mg 0.06 mg/kg 0.015 mg/kg

(Dilaudid) every 34 hr every 34 hr every 34 hr every 34 hr

Levorphanol 4 mg (acute) 2 mg (acute) 24 mg 2 mg 0.04 mg/kg 0.02 mg/kg

(Levo-Dromoran) 1 mg (chronic) 1 mg (chronic) every 68 hr every 68 hr every 68 hr every 68 hr

Meperidine 300 mg 100 mg NR 100 mg NR 0.051.5 mg/kg

(Demerol) every 3 hr every 24 hr

Methadone 20 mg (acute) 10 mg (acute) 510 mg 10 mg 0.2 mg/kg 0.1 mg/kg

(Dolophine, others) 24 mg (chronic) 24 mg (chronic) every 68 hr every 68 hr every 68 hr every 68 hr

Oxycodone 30 mg NA 510 mg NA 0.10.2 mg/kg NA

(Roxicodone) every 34 hr every 34 hra

Fentanyl NA 0.01 mg 5 mcg/kg 50100 mcg 515 mcg/kg 1 mcg/kg

Lozenge every 12 hr Oraletb

NR  Not recommended; NA  Not available

*For all parenteral opioids, start with the low dose and titrate to effective pain control.
a
Caution: Doses of aspirin and acetaminophen in combination with opioid/NSAID preparation must also be adjusted to the patients body weight.
b
The Oralet is not widely used because of nausea and vomiting side effects.
Data from American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and cancer pain (4th ed., pp. 68, 1415, 20). Glenview, IL: Author; Hazinski,
M. F. (1999). Analgesia, sedation, and neuromuscular blockade in pediatric critical care. In M. F. Hazinski, Manual of pediatric critical care (pp. 4472). St. Louis, MO: Mosby; and
Acute Pain Management Guideline Panel. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Quick reference guide for
clinicians (AHCPR Pub. No. 920020). Rockville, MD: Agency for Healthcare Policy and Research, U.S. Public Health Service, Department of Health and Human Services.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1218

1218 CHAPTER 42

NURSING PRACTICE TABLE 428 Signs and Symptoms

of Opioid or Sedative
Respiratory depression (unresponsiveness and a respiratory rate less Withdrawal
than 12 breaths/min in children less than 2 years of age) may
progress to respiratory arrest and is the major life-threatening com-
System Signs and Symptoms
plication of opioid administration. Clinical signs that predict the de-
velopment of respiratory depression include sleepiness, small pupils, Central nervous Irritability, increased wakefulness,
system tremulousness, hyperactive deep tendon
and shallow breathing. Children at particular risk for respiratory de-
reflexes, clonus, inability to concentrate,
pression induced by an opioid are those with an altered level of con- frequent yawning, sneezing, delirium,
sciousness, an unstable circulatory status, a history of apnea, or a hypertonicity, visual or auditory hallucinations
known airway problem. Some hospitals use continuous pulse oxime-
try when children at risk for respiratory depression receive opioids. Gastrointestinal Feeding intolerance with vomiting, diarrhea,
system uncoordinated suck and swallow
Respiratory depression is most likely to occur when the child is
sleeping. This augments the depressant effect on the respiratory cen- Sympathetic Tachycardia, tachypnea, increased blood
ter and potential airway obstruction by the tongue (American Pain So- nervous system pressure, nasal stuffiness, sweating, fever
ciety, 1999). Identify the time interval before drug-specific peak Data from Tobias, J. D. (2000). Tolerance, withdrawal, and physical dependency after
respiratory depression occurs, and then carefully monitor the childs long term sedation and analgesia of children in the pediatric intensive care unit.
vital signs during that period to detect respiratory depression. Nalox- Critical Care Medicine, 28(6), 21222132. Adapted.
one is the drug used for reversal of opioids adverse effects.

and connective tissue conditions. An NSAID may be pre-

life-threatening injuries, multiple surgeries, and invasive pro-
cedures for long-term treatment. Slowly weaning the child off
the opioid over 2 to 4 weeks will prevent withdrawal symp-
toms. See Table 428 for signs and symptoms of withdrawal.
Acetaminophen and Nonsteroidal Anti-inflammatory Drugs
NSAIDs such as aspirin, primarily given orally, are effective
for the relief of mild to moderate pain and chronic pain.
Table 429 presents recommended dosages of these drugs.
They are most commonly used for bone, inflammatory,
scribed in combination with an opioid to increase the ef-
fectiveness of the narcotic drug, which may ultimately
reduce the amount of opioids needed.
Acetaminophen is a nonnarcotic analgesic that is used
like an NSAID. It works by raising the pain threshold and
is equal to aspirin in analgesic properties.
DRUG ADMINISTRATION
Pain from surgery, major trauma, or cancer is present for
predictable periods because of the effects of tissue damage.

TABLE 429 Acetaminophen, NSAIDs and Recommended Doses for Children

and Adolescents

Oral NSAID Peak Action Time Usual Adult Dose Usual Pediatric Dose Comments
Acetaminophen 0.52 hr 5001000 mg every 46 hr 1015 mg/kg every Lacks the peripheral anti-inflammatory
46 hr activity of other NSAIDs; rectal suppository
available

Aspirin 12 hr 650975 mg every 46 hr 1015 mg/kg every Do not use in children under 12 years with
4 hr possible viral illness; may cause gastric upset
and bleeding; rectal suppository available

Choline magnesium trisalicylate 10001500 mg every 12 hr 25 mg/kg every 12 hr Does not increase bleeding time like other
(Trilisate) 2 hr NSAIDs; also available as oral liquid

Ibuprofen (Motrin, others) 0.5 hr 200400 mg every 46 hr 10 mg/kg every 68 hr Available as oral suspension

Naproxen (Naprosyn) 24 hr 500 mg initial dose followed 5 mg/kg every 12 hr Available as oral liquid
by 250 mg every 68 hr

Data from American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and cancer pain (4th ed., pp. 68, 1415, 20). Glenview, IL: Author; Hazinski,
M. F. (1999). Analgesia, sedation, and neuromuscular blockade in pediatric critical care. In M. F. Hazinski, Manual of pediatric critical care (pp. 4472). St. Louis, MO: Mosby; and
Acute Pain Management Guideline Panel. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Quick reference guide for
clinicians (AHCPR Pub. No. 92-0020). Rockville, MD: Agency for Healthcare Policy and Research, U.S. Public Health Service, Department of Health and Human Services.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1219
DRUG GUIDE
ACETAMINOPHEN
Overview of Action
Produces analgesia by unknown mechanism. Acts in the hypothala-
mus to cause antipyresis. Used in treatment of mild to moderate pain
and of fever. Does not have anti-inflammatory effects. Does not affect
bleeding time.
Routes, Dosage, Frequency
Oral or rectal: 10 to 15 mg/kg/dose every 4 to 6 hours, as needed.
Do not exceed 5 doses/day. If not prescribed by healthcare provider,
seek medical advice after 5 doses for either fever or pain. Children 12
years and older should not exceed 4 g per day.
Contraindications: Previous allergy to the drug and G6PD defi-
ciency. Do not give preparations with aspartame to children with
phenylketonuria. Use cautiously in children with hepatic dysfunction,
anemia, renal dysfunction, or rheumatoid arthritis.
Drug interactions: Chronic coadministration with carbamaze-
pine, phenytoin, barbiturates, and rifampin may increase potential for
chronic hepatotoxicity.
Side effects: Liver damage with overdose.
Pain relief should be provided around the clock. Every ef-
fort should be made to give the child analgesics without
causing more pain. The preferred routes of administration
are intravenous, local nerve block, and oral.
Continuous infusion analgesia is recommended for
children with continuous or persistent severe pain because
constant drug levels eliminate peaks and valleys in pain
control. Analgesics may also be given intravenously on a
scheduled basis (e.g., every 3 to 4 hours). Delays in giving
analgesics increase the chances of breakthrough pain and
the subsequent anticipation of pain. Giving analgesics on
an as-needed basis for acute pain also results in the loss of
pain control. More medications are often needed to restore
pain control than would have been required for continuous
infusion analgesia.
Patient-Controlled Analgesia
Patient-controlled analgesia (PCA) is a method of admin-
istering an intravenous analgesic, such as morphine, using
a computerized pump programmed by the healthcare pro-
fessional and controlled by the child (Skill 132). SKILLS A
continuous infusion of opioid prevents a recurrence of
pain during long sleeping periods. This method of pain
management is especially useful for pain control in the first
48 hours after surgery when oral pain management is not
possible. PCA is prescribed mostly for children 5 years of
age and older. Children selected for PCA should be able to
push the injection button and understand that pushing the
Pain Assessment and Management in Children 1219
Nursing Implications
Assess: Note hepatic and renal function. Assess pain level or
actual temperature prior to administration.
Administer: Follow dosage directions carefully for different liquid
preparations. Concentration differs between drops and elixir.
Plain or chewable tablets may be crushed and given with fluid;
avoid giving with high-carbohydrate meals, which can decrease
drug absorption.
Monitor: Evaluate the response to medication. Periodic renal and
hepatic studies may be ordered for patients on long-term therapy.
Patient teaching: Do not give with other over-the-counter
medications unless directed by healthcare provider as they may
also contain acetaminophen or aspirin. Consult a physician for
dosage in a child younger than 2 to 3 years, if fever or illness
persists over 3 days, or if relief is not obtained. Limit child to 5
doses/day. Store out of the childs reach as this medication is a
frequent cause of childhood poisoning.
Data from: Wilson, B. A., Shannon, M. T., & Stang, C. L. (2005). Prentice Hall nurses
drug guide. Upper Saddle River, NJ: Prentice Hall; Taketoma, C. K., Hodding, J. H., &
Kraus, D. M. (2002). Pediatric dosage handbook (9th ed.). Hudson, OH: Lexi-Comp.
button will give them medication to relieve pain. Parents
are sometimes given responsibility for pushing the injec-
tion button for younger children or those with disabilities.
After initial pain control has been achieved with an IV
infusion by the nurse, the child presses a button to receive
a smaller analgesic dose for episodic pain relief. Safety fea-
tures that include the ability to set the maximum number
of infusions per hour and the maximum amount of drug
received in a given time period prevent overdoses. Ad-
ditional pain medication is often ordered as needed to
supplement the continuous and patient-administered in-
fusion when pain control is not maintained.
Children and adolescents benefit from PCA by receiv-
ing continuous pain control and having the ability to con-
MEDIALINK
trol their comfort level with no trauma from injections.
Once children can take oral analgesics, PCA is discontinued.
REGIONAL PAIN MANAGEMENT
Skill 13-2: Patient Controlled Analgesia
Epidural pain control provides selective analgesia and has
become more common for postoperative pain manage-
ment. A catheter is inserted into either the lumbar or the
caudal space. Only minute doses of drugs are needed be-
cause of the high concentration achieved at the opioid
receptors in the spinal cords dorsal horn (Pasero, 2003).
Local nerve blocks, such as a popliteal block for anes-
thesia and analgesia of an extremity, are used more fre-
quently for pain control after surgery. A subcutaneous
catheter is inserted into the local area for infusion of the
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1220 CHAPTER 42
TEACHING HIGHLIGHTS
PATIENT-CONTROLLED ANALGESIA (PCA)
What is PCA? Analgesia means pain relief: you get to control the
amount of medicine you receive by using the machine.
The machine gives the medicine by passing it through the tube
that is connected to your intravenous line. When you push the
button, the machine pumps pain medicine into the intravenous
line to make you feel better.
The machine limits the amount of medicine you can get to what
the doctor orders. You can get any amount up to the maximum
by pushing the button repeatedly. The push button will not let
you make a mistake if you drop it or roll on it.
Whenever you feel pain, hurt, or discomfort, push the button to
get more medicine. You should be the only one to push the
button.
No needles for pain shots are needed as long as the intravenous
line is in place.
The PCA may not relieve all of your pain, but it should make you
feel comfortable. Let the nurse know if you think your PCA is not
working.
The PCA will be used until you can take pills or drink liquid pain
medicine.
analgesia. Pain control is achieved without systemic side ef-
fects from the medication. Tingling felt in the fingers or
toes of the affected extremity is the first sign that the nerve
block is receding.
NURSING MANAGEMENT
NURSING ASSESSMENT AND DIAGNOSIS
Nurses have an ethical obligation to relieve a childs suffer-
ing not only because of the consequences of unrelieved
pain but also because appropriate pain management may
have benefits such as earlier mobilization, shortened hos-
pital stays, and reduced costs. To provide effective nursing
management of children in pain, anticipate the presence of
pain and recognize the childs right to pain control.
When assessing pain in children, keep the following
questions in mind:
What is happening in tissues that might cause pain?
Assume that children who have had surgery, injury,
vaso-occlusive episode, or illness are experiencing pain,
since these events also cause pain in adults.
What external factors could be causing pain? For
example, is the cast too tight or is the child poorly
positioned in bed?
Are there any indicators of pain, either physiologic
or behavioral?
How is the child responding emotionally?
How does the child or parent rate the pain?
Physiologic symptoms such as nausea, fatigue, dyspnea,
bladder and bowel distention, and fever may influence
the intensity of pain felt by a child. Fear, anxiety, separa-
tion from parents, anger, culture, age, or a previous pain
experience may also affect the childs behavior or re-
sponses to pain stimuli.
When working with an infant or child, determine
which pain scale is the most appropriate for the circum-
stance and developmental stage. When using a self-report
pain assessment tool, use the same tool each time you assess
for pain or for the evaluation of pain management. This
makes comparison of assessment results possible. A
chronologic record of the childs pain assessments must be
documented along with actions taken to relieve pain, in ad-
dition to the follow-up assessments to determine the effec-
tiveness of those actions.
Remember that surgery and trauma can result in mul-
tiple sites of pain (incision or laceration, cut or bruised
muscles, interrupted blood supply, nasogastric tube place-
ment, insertion sites of intravenous lines). When using
pain scales in the assessment of a verbal child, attempt to
identify all sites of pain. Then evaluate the intensity of pain
at each site.
Examples of nursing diagnoses for children in pain in-
clude the following:
Acute Pain (abdominal) related to injury and surgery
Anxiety related to anticipation of pain from an
invasive procedure
Sleep Pattern Disturbed related to inadequate pain control
Ineffective Individual Therapeutic Regimen Management
related to self-management of pain control, and use of
nonpharmacologic pain-control measures
Ineffective Breathing Pattern: Potential for, related to
opioid overdose
Risk for Constipation related to opioid pain medication
and limited activity
PLANNING AND IMPLEMENTATION
Nursing management involves the following actions to in-
crease and maintain patient comfort once the assessment is
completed and nursing diagnoses are developed: pharma-
cologic intervention; nonpharmacologic intervention;
monitoring, evaluating, and documenting the effectiveness
of pain-control measures to provide optimal comfort; and
patient education.
The accompanying Nursing Care Plan summarizes
nursing care for the child with postoperative pain.
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Pain Assessment and Management in Children 1221

NURSING CARE PLAN

THE CHILD WITH POSTOPERATIVE PAIN

Intervention Rationale Expected Outcome

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

NIC Priority Intervention: NOC Suggested Outcome:

Pain management: Alleviation of pain or a
reduction in pain to a level of comfort that is
acceptable to the patient
Goal: The child will report relief (to a level acceptable to the child on a pain scale).
Give analgesic by a pain-free method.
Have the child select a pain scale and
rate the amount of pain perceived before
and 3060 minutes after analgesia is
given to ensure pain relief.
Assess pain control each hour to ensure
that the childs pain is relieved.
Reposition the child every 2 hr to
maintain good body alignment.
Provide therapeutic touch or massage.
Encourage the parents to read a story or
play favorite music.
Comfort level: Feelings of physical and
psychologic ease
The child may deny pain to avoid The child reports pain relief after
analgesia by painful route. administration of analgesia.
The childs pain rating is the best
indicator of pain. Maintenance of pain
control requires less analgesia than
treating each acute pain episode.
Frequent monitoring identifies inadequate
pain control before it becomes
significant.
New positions decrease muscle cramping
and skin pressure.
Complementary therapy reduces stress
and enhances the analgesic action.

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

NIC Priority Intervention: NOC Suggested Outcome:
Sleep enhancement: Facilitation of regular Sleep: Extent and pattern of sleep for
sleep/awake cycles mental and physical rejuvenation

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

Give analgesia by continuous infusion or Pain breakthrough occurs even during The childs sleep is undisturbed by pain.
every 34 hr around the clock. sleep and disturbs the healing effects of Child sleeps for age-appropriate number of
sleep. hours per day.

3. Nursing Diagnosis: Ineffective Individual Therapeutic Regimen Management related to self-management of pain control and use of
nondrug pain-control measures
NIC Priority Intervention: NOC Suggested Outcome:
Self-modification assistance: Treatment behavior pain control: Personal
Reinforcement of self-directed change actions to palliate or eliminate pain
initiated by the patient to achieve personally
important goals

Goal: The child and family will effectively use patient-controlled analgesia (PCA) and complementary therapy pain-control measures.
Teach the child how the PCA works and The child must know that pushing the The childs pain rating stays low.
when to push the button. PCA button will keep pain under control.
Teach the family and the child how to use Complementary therapy pain-control The child and family independently use
age-appropriate imagery, distraction, measures reduce the amount of complementary therapies for pain control.
relaxation techniques, and other analgesia needed.
complementary therapy pain-control
measures.

Goal: The child and family will use appropriate analgesia after discharge.
Discuss appropriate pain control to use The family and child may be anxious The family understands pain-relief measures
at home after discharge. about pain management at home. for use at home and knows where to call if
help is needed.

(continued)
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1222 CHAPTER 42

NURSING CARE PLANcontinued

THE CHILD WITH POSTOPERATIVE PAIN

Intervention Rationale Expected Outcome

4. Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to opioid overdose
NIC Priority Intervention:
Respiratory monitoring: Collection and
analysis of patient data to ensure airway
patency and adequate gas exchange
Goal: The child will maintain adequate ventilations.
Verify that correct dose of opioid
analgesia is given for the childs weight.
Monitor vital signs and depth of
inspirations before analgesic is
administered and at time of peak drug
action.
Calculate agonist dose ordered by
physician to be sure it will reverse
respiratory depression, but not counteract
effect of analgesia.
NOC Suggested Outcome:
Vital signs status: Temperature, pulse,
respirations, and blood pressure within
expected range for the individual
Respiratory depression is a significant There is no episode of respiratory depression
complication of opioid analgesia when associated with analgesia.
too much analgesia is given.
Respiratory depression episode must not
progress to respiratory arrest. All opioids
act on brainstem center, which decreases
responsiveness to CO2 tension.
Valuable time will be saved if agonist is
needed for episode of respiratory
depression. Complete reversal of
analgesia will cause the child to have
significant pain.

5. Nursing Diagnosis: Constipation related to opioid administration and decreased motility of gastrointestinal tract
NIC Priority Intervention: NOC Suggested Outcome:
Constipation management: Prevention and Bowel elimination: Ability of gastrointestinal
alleviation of constipation tract to form and evacuate stool effectively.

Goal: The child will have minimal constipation.

Palpate the abdomen, and assess bowel
sounds and abdominal distention.
Request physician order for stimulating
laxative and stool softener.
Provide fluids of choice to increase fluid
intake when IV fluids are decreased.
Inform family and child that constipation
is a side effect of pain medication.
Signs of constipation must be anticipated The child has bowel movements at least
and identified. every 2 days while on opioid pain control.
Opioids increase the transit time of feces
and interfere with bile enzymes needed
for evacuation.
Extra fluids will counteract opioid action
of increasing the absorption of water from
the large intestine.
Parents can become partners in
managing fluid intake and monitoring
bowel movements.

Pharmacologic Intervention
Give analgesics as ordered by the physician, ensuring that the
dose is appropriate for the childs weight. When administer-
ing an opioid by intravenous infusion or PCA, monitor the
flow rate and the site for infiltration. Monitor the childs vi-
tal signs for complications related to opioids, such as respi-
ratory depression.Vital signs (heart rate and blood pressure)
may not change in response to effective analgesia when in-
fection, trauma, or other stressors keep them elevated. Check
for the presence of other side effects of analgesics, such as se-
dation, nausea, vomiting, itching, urinary retention, and
constipation. Make sure analgesic antagonists such as nalox-
one are available should complications develop.
NURSING PRACTICE
Naloxone may be used to treat respiratory depression caused by an
opioid drug at a dose and slow infusion rate that does not reverse the
pain-control effects of the narcotic. A continuous infusion or repeated
doses may be needed for severe overdoses.
When a regional nerve block is used, the analgesic ef-
fect does not recede for several hours after the catheter is
removed. Be careful when ambulating a child with a re-
gional nerve block in an extremity. Protect the extremity
from injury because the child has reduced feeling in the
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1223
limb. Monitor the child for tingling of fingers or toes, an in-
dication that the analgesic effect is receding. Begin oral
analgesia to maintain pain control.
Oral NSAIDs are generally ordered for less severe pain
or chronic pain. These drugs may mask fever. Be alert to the
potential complication of gastrointestinal hemorrhage in
critically ill children who have increased gastric acids as a
physiologic stress response to pain.
Assess the child for pain 15 to 30 minutes following in-
travenous pain medication and 1 hour after oral pain med-
ication to determine if adequate pain control was achieved.
Evaluate the childs level of pain frequently to identify any
increase in pain intensity. Use information collected from
the child and parent, as well as from an appropriate pain
scale. Dramatic reductions in pain should occur, although
not all pain may disappear. Be certain to record results of
pain-control measures to guide future nursing actions. Use
a flowsheet to document assessments and medication ad-
ministration during the postoperative period.
Many children sleep after receiving an analgesic. This
sleep is not a side effect of the drug or a sign of an overdose,
but the result of pain relief. Pain interrupts sleep, and once
pain is relieved, the child can sleep comfortably. However,
sleep does not always indicate pain control. A child in pain
may fall asleep in exhaustion. Look for other symptoms of
pain, such as excess movement or moaning.
EVIDENCE-BASED NURSING
GIVING CHILDREN ADEQUATE PAIN MEDICATION
Clinical Question
Why does adequate management of children with acute pain continue
to be a problem?
Evidence
In several recent studies, researchers found that some children continue
to be undermedicated for moderate and severe pain despite continuing
efforts to promote effective pain management for children (Higgins, Tur-
ley, Harr et al., 1999; Vincent, 2001; Vincent & Denyes, 2004). A study
by Vincent and Denyes in 2004 explored factors related to the actions
67 nurses took to relieve childrens pain in actual clinical situations in a
childrens hospital. The 132 children were experiencing pain from
surgery, burns, vaso-occlusive episodes, and trauma. Nurses studied
had a moderately high level of knowledge and attitudes about relieving
childrens pain. Behavioral manifestations of pain led more nurses to be-
lieve a childs self-report of pain. Nurses did tend to give more analge-
sia to children reporting higher pain levels, meaning that the childs pain
level is what triggered the nurses to administer analgesia.
Implications
Surprisingly, 26% of children reporting pain received no analgesia, and
the 51% of children with moderate to high levels of reported pain re-
ceived markedly less than the recommended and ordered amounts of
Pain Assessment and Management in Children 1223
Become an advocate for children when the dose or type
of analgesic ordered is inadequate. Tolerance is a decrease
in a drugs effect over time or the need for increasing
amounts of the drug to produce or maintain the same level
of pain relief or sedation effect. This may occur when chil-
dren with severe pain have been taking opioids or sedatives
for several days. Breakthrough pain occurs, and an increase
in dosage is needed to achieve the previous level of pain re-
lief. Tolerance can be delayed with effective use of pain
scales to allow appropriate drug dosing, and often less anal-
gesia is needed. Magnesium may also slow the develop-
ment of tolerance (Tobias, 2000).
Before asking the physician to change the analgesia, re-
view the childs record for documentation that the pre-
scribed drug has been given at the appropriate dose and
frequency and that the childs pain relief is ineffective despite
the drug administration. After verifying the record, provide
the physician with information about the characteristics of
the childs pain and ask that the medication be changed.
Nonpharmacologic Intervention
Complementary therapies are the nonpharmacologic
methods of pain control that can be used with or without
analgesics. The gate control theory helps explain why com-
plementary pain management techniques are effective in
helping to control pain. Stimulation of the larger A-delta
analgesia. Pediatric nurses have an obligation to ask children to report
their pain levels and then to accept that this pain rating is accurate. Be-
havioral cues that pain exists should not be necessary to evaluate pain
in children who can self-report pain. Crying and grimacing in pain are
not the only pain behaviors to look for. Pain behaviors vary among chil-
dren. For example, children use play as a distraction to self-manage
pain, and they sleep after becoming fatigued from dealing with pain.
Children are entitled to comfort and pain relief, so all information that
informs the nurse that the child is experiencing pain should be used in
making decisions to relieve pain.
Critical Thinking
What could be some reasons for undermedication of children by
nurses? What is your role in improving the pain management of children
in all settings?
References
Vincent, C. V., & Denyes, M. J. (2004). Relieving childrens pain: Nurses abilities and
analgesic practices. Journal of Pediatric Nursing, 19(1), 4050.
Vincent, C. V. (2001). Nurses analgesic practices with hospitalized children. Journal
of Child and Family Nursing, 4(2), 7989.
Higgins, S. S., Turley, K. M., Harr, J., & Turley, K. (1999). Prescription and administration
of around the clock analgesics in postoperative pediatric cardiovascular surgery
patients. Progress in Cardiovascular Nursing, 14(1), 1924.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1224

1224 CHAPTER 42

vision or a video, and focusing on a picture while counting.

TEACHING HIGHLIGHTS
HELPING A CHILD COPE WITH PAIN
Parents are the single most powerful nonpharmacologic method of
pain relief available to children. A parents presence greatly reduces
the anxiety associated with pain and hospitalization (Broome, 2000).
Children often feel more secure telling their parents about their pain
and anxiety. When parents are actively participating in the childs care
during hospitalization, teach them about how complementary thera-
pies can be used to enhance the childs pain management. Help the
parent select the age-appropriate complementary therapy for the
child:
Infants: holding, cuddling, sucking a pacifier, massage
Toddlers: massage, stories, bubbles, touch, holding and rocking,
music (Figure 425)
Preschoolers: engaging in play, stories, music, imagining being a
superhero, watching television or a video
School-age children: rhythmic breathing, muscle relaxation,
guided imagery, talking about pleasant experiences, playing
games, listening to radio, watching television or a video
Adolescents: rhythmic breathing, muscle relaxation, guided
imagery, having visitors, playing games, watching television,
listening to radio or CD player
Select activities that are developmentally appropriate for
the child. Children in severe pain cannot be distracted, but
do not assume the pain is gone if a child can be distracted.
Cutaneous Stimulation. Cutaneous stimulation involves gen-
tly rubbing the painful area, massaging the skin gently, and
holding or rocking the child. Touching provides a stimulus
to compete with the pain stimuli transmitted from the pe-
ripheral nerves to the spinal cord. These actions may re-
duce the pain felt by the child. Swaddling and blanket rolls
may calm a distressed newborn by decreasing tactile stim-
ulation and containing gross motor behaviors (Lynn,
Ulma, & Spreker, 1999).
Sucrose Solution. Concentrated sucrose solutions (12% or
24%) with a pacifier may be used as a pain relief measure
in newborns. Sucrose may provide a natural pain relief by
activating endogenous opioid systems in the body. The
analgesic effect of sucrose lasts approximately 3 to 5 min-
utes, with a peak action in 2 minutes (Mitchell & Waltman,
2003). A moistened pacifier dipped in a packet of sugar
given to the infant during a painful procedure reduced pain
behaviors such as duration of crying and vagal tone during
a heel stick (Greenberg, 2002).

FIGURE 425
fibers by nonpainful touch and pressure such as massage
causes the substantia gelatinosa in the dorsal horn of the
spinal cord to close the gate and decrease the transmis-
sion of pain impulses to the brain (Franck, Greenberg, &
Stevens, 2000; Huether & Leo, 2002). See Pathophysiology
Illustrated on page 1209.
One or more of these methods may provide adequate
relief of low levels of pain. When used with analgesics, non-
pharmacologic techniques often increase the effectiveness
of the analgesic or reduce the dosage required. When used
in association with a medical procedure, remember to use
an intervention before, during, and after the procedure.
This gives the child a chance to recover, feel mastery, and
remember coping (Fanurik, Koh, Schitz et al., 1997).
Assemble a pain management kit to promote distrac-
tion, imagery, and relaxation in children. Items that might be
included are magic wands, pinwheels, bubble liquid, a slinky
spring toy, a foam ball, party noisemakers, and pop-up
books. It may also be helpful to include items for therapeu-
tic play such as syringes, adhesive bandages, alcohol swabs,
and other supplies from a medical kit. The pain management
kit may be especially helpful for distracting children who are
being prepared for surgery or for painful procedures.
Distraction. Distraction involves engaging a child in a wide
variety of activities to help him or her focus attention on
something other than pain and the anxiety associated with The presence of the parent is an important part of pain management. Chil-
the procedure. Examples of distracting activities are listen- dren often feel more secure telling their parents about their pain and anxiety.
ing to music, singing a song, playing a game, watching tele-
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1225
Electroanalgesia. Also known as transcutaneous electrical
nerve stimulation (TENS), electroanalgesia delivers small
amounts of electrical stimulation to the skin by electrodes.
This electrical stimulation is stronger than the pain im-
pulses, and because of the gate control theory, is thought to
interfere with the transmission of pain from the peripheral
nerves to the spinal cord. TENS may be used for both acute
and chronic pain management. The only known side effect
is skin irritation at the electrode site.
Guided Imagery. Imagery is a cognitive process that encour-
ages the child to focus concentration on an event or place
unrelated to the pain process. The focus can be on explor-
ing a favorite place, doing a favorite activity, remembering
a funny story, or being a superhero. This method is most ef-
fective in children over 6 years of age. Ask the child to think
about all the sights, sounds, smells, tastes, and feelings that
will help him or her to experience the favorite place, activ-
ity, or story. Guided imagery is a form of self-hypnosis, and
it is most effective when preceded by a relaxation exercise.
Relaxation Techniques. Relaxation techniques are used to re-
duce muscle tension, which aggravates pain. Relaxation
methods include rhythmic breathing and alternately tens-
ing and relaxing selected muscle groups for 10 seconds
each. Progressively move from specific muscle groups to
more central muscles. Enhance relaxation by focusing the
childs attention on something pleasant.
Hypnosis. An altered state of consciousness occurs when
appropriate suggestions distort perception, memory, and
mood. Children who respond to hypnotic suggestions are
often more relaxed and experience less pain. The precise
physiologic mechanism for the success of hypnosis in pain
control is not known; however, the gate control theory may
be a factor.
Application of Heat and Cold. Heat application promotes dila-
tion of blood vessels. The increased blood circulation per-
mits the removal of debris of cell breakdown from the site.
Heat also promotes muscle relaxation, breaking the
painspasmpain cycle. To reduce edema, do not apply
heat in the first 24 hours after an injury.
The application of cold is believed to slow the ability of
pain fibers to transmit pain impulses. Cold also controls
pain by decreasing edema and inflammation and by caus-
ing partial or complete anesthesia or numbness of the skin.
When cold is applied, assess the skin for redness or signs of
irritation. Take care to avoid causing thermal injury. Dis-
continue cold applications immediately if the skin alter-
nately blanches and reddens afterwards or if blisters or
redness do not subside between applications.
Discharge Planning and Home Care Teaching
Children are frequently discharged from the hospital with
oral analgesics following surgery, injury, or treatment of
acute medical conditions. Parents have the responsibility
Pain Assessment and Management in Children 1225
MEDIALINK
COMPLEMENTARY CARE
HYPNOTHERAPY FOR CHILDREN
The most widely studied of the complementary/alternative therapies,
hypnotherapy is often successfully prescribed as the primary treat-
Hypnotherapy for Children
ment for a variety of childhood problems, including pain, bed-wetting,
asthma, stool-withholding, habit disorders, anxiety and fears, migraine
headaches, nausea from chemotherapy, needle phobias, warts, in-
somnia, tics, and other problems (Anbar, 2003; Thompson, 2004).
Children have a great capacity to use their imaginations and fan-
tasy worlds for therapeutic gain and are actually more successful than
adults in attaining a hypnotic state. Children entering a healthcare en-
vironment are often fearful. As the nurse, you can induce a more re-
laxed state in children by speaking quietly, focusing them on their
breathing, and suggesting they imagine something pleasantthe in-
gredients of hypnotic induction.
Hypnosis is an altered state of awareness facilitating heightened
concentration, decreased awareness of external stimuli, increased re-
laxation, and increased suggestibility. Hypnotherapy can be as simple
as teaching a child to blow on a pinwheel while getting an injection.
This diminishes the pain and fear of the needle by focusing the childs
heightened attention elsewhere. More formal hypnotherapy is done by
a therapist trained in pediatric hypnotherapeutic techniques that use
the images and language of the child to induce relaxation and give
posthypnotic suggestions. Language such as, You are the boss of
your body and can help make this headache not bother you anymore
is used to help children gain mastery over their physical symptoms.
to provide adequate pain control for their child after day
surgery. The child usually leaves the surgical center pain-
free, and the parents may not anticipate pain. Take the
time to discuss the importance of pain management and
its benefits in promoting the childs healing. Make sure
parents know that a sudden increase in pain intensity in-
dicates the development of a complication requiring med-
ical attention.
Provide guidance to help parents assess their childs
pain, and for school-age children and adolescents to assess
their own pain. Teach parents and children about the
dosage and frequency of administration and the side effects
of the analgesic ordered. Review nonpharmacologic meth-
ods of pain control with parents and children. Encourage
children and parents to use the techniques that work best
for them.
Remember that many common health problems (oti-
tis media, pharyngitis, and urinary tract infection) have
pain as one of the presenting symptoms. Often the only
medication prescribed is an antibiotic to clear the infec-
tion. This may leave the child in pain for 48 to 72 hours
until the antibiotic brings the infection under control.
Give parents recommendations for pain control and com-
fort measures during this period. Review the dose, dosing
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1226
1226 CHAPTER 42
device, and formulation of acetaminophen used by par-
ents to identify any risk for overdose.
EVALUATION
Expected outcomes of nursing care include the following:
The childs pain level is assessed frequently and pain
management is effective in improving the childs comfort.
The child successfully uses a PCA pump to control
acute pain.
Age-appropriate nonpharmacologic methods of pain
management enhance the comfort provided by
medications.
NURSING MANAGEMENT OF CHRONIC PAIN
Some children have medical conditions that cause chronic
pain and episodic acute pain, such as rheumatoid arthritis,
cancer, headaches, recurrent abdominal pain, and HIV in-
fection. Chronic pain does not arouse the sympathetic ner-
vous system in the same way that acute pain does. Therefore
the child may perceive pain but not appear to be in pain.
Physical and psychologic signs and symptoms should
be viewed together. No tools have been developed to assess
chronic pain for any child age group. Assessment and eval-
uation of chronic pain in children should include the fol-
lowing aspects (American Pain Society, 2003):
Approach pain as the present problem and obtain the
history of pain onset, its development over time,
intensity, duration, location, what makes it worse or
relieves it, and its impact on daily life (sleeping,
appetite, school, and social interactions).
Determine the amount of distress the child and family
experience with pain, including anxiety, depression,
and hopelessness.
Clarify what the family and child believe causes the
pain and their response to it.
Identify past pain problems in the family and the
current methods of treatment.
Observe the childs appearance, posture, gait, and
emotional and cognitive state.
Assess muscle spasms, trigger points, areas sensitive to
light touch, and a complete neurologic examination.
Older children with recurrent episodes of pain can be en-
couraged to keep a diary or log to describe the character-
istics, timing, activities, and potential triggers of their
pain, as well as their response to pain treatment mea-
sures. A pain assessment scale should be used to rate the
pain intensity before and after medications and other
pain-control measures are used. This record can help im-
prove pain management.
Examples of nursing diagnoses for children with
chronic pain include the following:
Chronic Pain related to arthritic joint inflammation
and degeneration
Disturbed Sleep Pattern related to ineffective
management of chronic pain
Impaired Physical Mobility related to ineffective
management of chronic pain
Children with chronic conditions (arthritis, sickle cell dis-
ease, hemophilia, cancer, recurrent headaches, etc.) often
need long-term pain management. NSAIDs and aceta-
minophen are often ordered for pain management. Strate-
gies for chronic pain management include the following:
Explain and validate pain and its causes.
Encourage the use of a pain diary.
Discuss treatment goals with the child and family and
jointly develop a care plan that integrates
pharmacologic and nonpharmacologic
(complementary) methods.
Develop a care plan for sudden painful episodes
associated with acute flare-ups of their condition.
Provide effective preventive pain management for
procedural pain, as many of these children have
numerous medical procedures.
Parents should be actively engaged in pain control for their
child. Teach parents the importance of pain control and
how to use a variety of complementary therapies with their
child to supplement the pain medications administered.
Refer children with long-term pain to a pediatric pain pro-
gram to be evaluated for customized strategies to manage
pain.
SEDATION AND PAIN MANAGEMENT
FOR MEDICAL PROCEDURES
Children undergo a wide variety of painful diagnostic and
treatment procedures in the hospital and in outpatient set-
tings. Procedures such as chest tube insertion, arterial
puncture, lumbar puncture, bone marrow aspiration, frac-
ture reduction, laceration repair, insertion of a central or
peripheral intravenous line, and burn debridement cause
significant pain in children. The anticipation of these pro-
cedures causes anxiety and emotional distress that can lead
to greater intensity of pain. Children who have experienced
severe pain in the past may be unwilling to cooperate with
healthcare personnel.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1227
CLINICAL THERAPY
Minor Medical Procedures
Topical anesthetics can be used to reduce the pain associated
with the first needle stick.Vapocoolant sprays can be used for
injections. Eutectic mixture of local anesthetics (EMLA)
cream, a mixture of 2.5% lidocaine and 2.5% prilocaine in an
emulsion, is effective if applied 60 minutes before a needle
stick procedure on intact skin (Rogers & Ostrow, 2004). See
Figure 426 . A new preparation (ELA-MAX, 4% liposo-
mal lidocaine) is effective if applied 30 minutes before a nee-
dle stick (Eichenfield, Funk, Fallon-Friedlander et al., 2002).
A local anesthetic such as lidocaine buffered by sodium
bicarbonate is often injected to provide analgesia for emer-
gency invasive procedures. Lidocaine can also be injected
subcutaneously in a small area to reduce the pain of deeper
needle insertion.
Sedation
Sedation is a medically controlled state of depressed con-
sciousness (light to deep) used for painful diagnostic and
therapeutic procedures. Procedures such as burn debride-
ment, laceration repair, bone marrow aspiration, and frac-
ture reduction are associated with so much pain and anxiety
FIGURE 426
A child what sensations to expect and what will happen dur-
B if the child should progress to deep sedation. In case complications
When painful procedures are planned, use EMLA cream to anesthetize the
skin where the painful stick will be made. A, Apply a thick layer of cream
over intact skin (one half of a 5-g tube). B, Cover the cream with a trans-
parent adhesive dressing, sealing all the sides. The cream anesthetizes the
dermal surface in 45 to 60 minutes.
Pain Assessment and Management in Children 1227
that children need premedication with analgesia and
anxiolysis, mild sedation. Sedation is often used to gain the
cooperation of the child for the medical procedure. Drugs
for sedation include the following (Proudfoot, 2002):
Benzodiazepines: diazepam (Valium), midazolam
(Versed), and lorazepam (Ativan)
Hypnotics or barbiturates: thiopental, pentobarbital
Ketamine
Propofol (Diprivan)
Analgesics: Fentanyl, Alfentanil
When sedatives are given in lower doses, light sedation oc-
curs during which the child maintains protective reflexes,
maintains a patent airway, and appropriately responds to
verbal stimuli. Deep sedation is a controlled state of de-
pressed consciousness or unconsciousness in which the
protective reflexes are lost. See Table 4210. Analgesia must
be given in association with sedation because the sedated
child can still feel pain but not communicate its presence.
Guidelines should exist in every healthcare facility
MEDIALINK
where pediatric sedation is performed to ensure safe health-
care practices. These guidelines often require that the health
professionals monitoring the child have specific qualifica-
tions, such as pediatric advanced life support training. With
the combined effects of analgesia and sedatives, the child
Skills 13-3 and 13-4
must be carefully monitored for respiratory depression and
signs of deep sedation. Antagonist agents are available for
opioids and benzodiazepines when the effects of sedation
and respiratory depression need to be reversed. (See Skills
133 and 134 for more information. SKILLS )
NURSING MANAGEMENT
Increase Comfort During Painful Procedures
Help the child cope with a painful procedure by telling the
ing the procedure. This reduces stress more effectively than
just providing information about the procedure. See
Chapter 39 for methods of preparing children of different
developmental ages for procedures.
NURSING PRACTICE
Whenever sedation is given, be sure to have the resources available
to monitor the childs vital signs and to provide advanced life support
occur, the following equipment should be immediately available: suc-
tion apparatus, a bag-valve mask for assisted ventilation with capa-
bility of 90% to 100% oxygen delivery, and an oxygen supply (5 L/min
for more than 60 minutes). Antagonists to sedative medication must
be premeasured and ready to administer.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1228
1228 CHAPTER 42
TABLE 4210 Characteristics of Light and Deep Sedation
Assessment Factors
Airway Able to maintain airway independently and continuously
Cough and gag reflexes Reflexes intact
Level of consciousness Easily aroused with verbal or gentle physical stimulation
Data from Proudfoot, J. (2002). Pediatric procedural sedation and analgesia (PSA): Keeping it simple and safe. Pediatric Emergency Medicine Reports, 7(2), 12.
Drug therapy is not always used for quick procedures,
such as a dressing change, or an unexpected intravenous
insertion, injection, or venipuncture. Complementary
therapies, especially guided imagery, relaxation techniques,
and distraction, may reduce the anxiety associated with the
anticipation of the procedure. Teach parents and children
to use these interventions before procedures. Help children
control their anxiety through therapeutic play.
When pharmacologic pain management is used for a
procedure, the nurses responsibilities include the following:
Treat anticipated procedure-related pain
prophylactically. For example, give an analgesic before
a bone marrow aspiration or fracture reduction.
Permit time for the drug to become effective.
Manage preexisting pain before beginning a procedure
such as scrubbing a burn.
Whenever possible, administer drugs by a nonpainful
route (oral, transmucosal, intravenous). Avoid
intramuscular or subcutaneous injections.
When procedures must be repeated (for example, bone
marrow aspirations for children with leukemia), give
optimal analgesia for the first procedure to reduce
anxiety about future procedures.
Critical Concept Review
LEARNING OBJECTIVES
Describe the physiologic and behavioral
consequences of pain in children.
Light Sedation Deep Sedation
Unable to maintain airway independently or continuously
Partial or complete loss of reflexes
Not easily aroused, may not respond purposefully to
verbal or gentle physical stimulation
To prevent increased anxiety, avoid delays in
performing procedures.
Document the results of pain management.
When the child receives sedation, monitoring the childs sta-
tus is important. Nursing assessments include visual confir-
mation of respiratory effort, color, and vital signs. Pulse
oximetry and other technology may be used for monitor-
ing, but the equipment must not replace visual assessment.
Vital signs must be checked every 15 minutes until the child
regains full consciousness and level of functioning. If light
sedation progresses to deep sedation, airway management is
essential; check vital signs every 5 minutes.
Criteria for discharge after sedation include the fol-
lowing (Bindler & Ball, 2003):
Satisfactory and stable cardiovascular function and
airway patency.
Easily arousable, protective reflexes intact.
Adequate hydration.
Infant is able to hold the head up and sit up unassisted
if old enough to do so, or the child can stand and walk
without assistance.
Discharge status is the same as admission status.
CONCEPTS
1. Physiologic consequences of acute pain:
Tachycardia and rapid shallow breathing.
Inadequate cough.
Inadequate lung expansion.
Depressed immune response.
Increased perspiration and loss of electrolytes and fluids.
Increased intestinal secretions.
lon23944_ch42.qxd 2/17/06 8:54 AM Page 1229
LEARNING OBJECTIVES
Describe the physiologic and behavioral
consequences of pain in children.continued
Select an appropriate tool to assess the
pain of infants and children in each age
group.
Describe the nursing assessment and
management for a child receiving an opioid
analgesic.
Explain the rationale for the effectiveness for
nonpharmacologic (complementary)
methods of pain control.
Assess children of different ages with acute
pain and develop a nursing care plan that
integrates pharmacologic interventions and
developmentally appropriate
nonpharmacologic (complementary)
therapies.
Develop a nursing care plan for assessing
and monitoring the child having sedation
and analgesia for a medical procedure.
Pain Assessment and Management in Children 1229
CONCEPTS
2. Behavioral consequences of acute pain:
Short attention span.
Irritability.
Facial grimacing.
Posturing, protecting painful area, immobility.
Lethargy or withdrawal.
Sleep disturbance.
1. Infants and nonverbal children:
Neonatal infant pain scale.
FLACC Behavioral Pain Assessment Scale.
2. Young children:
Color area of pain on outline of body.
Faces pain scale.
Oucher scale.
3. Older children and adolescents:
Visual analog scale.
Poker chip scale.
Word graphic scale.
Adolescent pediatric pain tool.
1. Use oral and intravenous route, if possible.
2. Titrate dose to match childs cardiorespiratory status.
3. Identify line of peak drug effect and monitor childs vital signs to detect respiratory depression.
4. Observe for nausea, constipation and itching.
5. Have nalaxone (Narcan) available for treatment of respiratory distress.
Nonpharmacologic methods of pain control are effective in children due to the Gate Control Theory.
The use of methods such as nonpainful touch and massage stimulate the larger A-delta fibers and
decrease the transmission of pain impulses to the brain.
Interventions common to all ages:
1. Assess pain frequently.
2. Anticipate need for pain medication.
3. Monitor vital signs.
Pharmacologic and nonpharmacologic interventions by age group:
1. Infants and toddlers:
Administer oral or intravenous medications around the clock.
Hold, swaddle, rock, or provide nonnutritive sucking.
Allow infant to suck sucrose solution.
Have toddler blow bubbles.
2. Preschooler:
Use distraction techniques with the use of a magic wand, pinwheel, or noise maker.
Allow child to watch appropriate TV shows or videos.
3. School-age child and adolescent:
Instruct in use of PCA or epidural until able to take oral medications.
Use hypnotherapy if child is able to cooperate.
Engage child in breathing techniques for relaxation.
Use guided imagery, visitors, TV, radio, tapes, or CDs for distraction.
1. Explain procedure to the child and parents.
2. Administer medications by oral or intravenous route, if possible.
3. Employ nonpharmacologic methods such as distraction and guided imagery to decrease
anxiety.
4. Use pulse oximetry and a cardiorespiratory monitor during procedure.
5. After procedure is completed, check vital signs and level of consciousness frequently until child
is stable and awake.
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1230 CHAPTER 42

CRITICAL THINKING IN ACTION

View the Critical Thinking in Action video in Chapter 42 of the CD-ROM. Then, answer the questions that follow.
A 12-year-old boy, Kevin, is
recovering from a 4-wheeler
accident on the medical
surgical unit at a local
childrens hospital. He was
riding the 4-wheeler
unsupervised and without
permission while his parents
were at work. He suffered an
abdominal injury requiring
surgery, three broken bones
and several lacerations that needed stitches. His parents are very worried
about his injuries and at the same time angry with him for not following
the rules. Kevin appears expressionless in his hospital bed, but cries and
grimaces at any slight movement. When asked on a scale of 110
(10 being the most pain) how much pain he is feeling, he says a 10. His
parents are reluctant to let him have any pain medications because they
fear he may become dependent on the medication. His father states that
Kevin should be a man and tolerate the pain, and he thinks enduring the
pain will teach him a lesson about responsibility. The nurse explains that
pain management is necessary to improve Kevins healing, help him
mobilize sooner, and potentially shorten his hospital stay. She explains
the physiological consequences of ineffective pain management and
discusses how the medication will help him sleep and rest. She explains
that some of pain medications can be addicting, but the chances of
Kevin becoming addicted to pain medications for this injury are
extremely rare. She also reviews the nonpharmacological methods of
relieving pain. The parents are still reluctant to the medications, but agree
to conform to the doctors orders.
1. What are some of the potential physiological consequences to
letting Kevin suffer pain?
2. What are some examples of opioid analgesics available to Kevin?
3. What are some examples of NSAIDs available to Kevin?
4. What are the signs and symptoms of opioid withdrawal and how
long should it take for Kevin to be weaned off an opioid?

MEDIALINK www.prenhall.com/london

NCLEX-RN Review, case studies, and other For animations, more NCLEX-RN Review
interactive resources for this chapter can be questions, and an audio glossary, access the
found on the Companion Website at accompanying CD-ROM in this textbook.
http://www.prenhall.com/london. Click on
Chapter 42 and select the activities for this
chapter.

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