Pediatric Pain Assessment

Pediatric Pain Assessment

Susan Harp, RNSusan Harp, RNDivision of Pediatric Anesthesia and Pain ManagementDivision of Pediatric Anesthesia and Pain Management

Goals of Pain AssessmentGoals of Pain Assessment

““Provide accurate information to Provide accurate information to determine which actions could be taken determine which actions could be taken to alleviate the pain, and, on an ongoing to alleviate the pain, and, on an ongoing basis evaluate the effectiveness of basis evaluate the effectiveness of these actions.”these actions.”

Judith Beyer and Nancy Wells, Judith Beyer and Nancy Wells,

PEDIATRIC CLINICS OF NORTH AMERICA,1989PEDIATRIC CLINICS OF NORTH AMERICA,1989

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Pain AssessmentPain Assessment

• LocationLocation• CharacteristicsCharacteristics• Onset / DurationOnset / Duration• FrequencyFrequency• QualityQuality• Intensity / SeverityIntensity / Severity• Precipitating FactorsPrecipitating Factors

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Assessment ToolsAssessment Tools

• Self-Report “The Gold Standard”Self-Report “The Gold Standard”

• Observational ScalesObservational Scales

• Physiologic ParametersPhysiologic Parameters

• Parent ReportParent Report

• Nurse ReportNurse Report

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Self-ReportSelf-Report

• Description of PainDescription of Pain- type of pain- type of pain- intensity of pain- intensity of pain

• Pain Scale RatingsPain Scale Ratings

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

ObservationsObservations

• Vocalization / verbalizationVocalization / verbalization

• Facial ExpressionFacial Expression

• Body LanguageBody Language

• Emotional StateEmotional State

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Physiologic ParametersPhysiologic Parameters

• Heart rateHeart rate

• Respiratory rateRespiratory rate

• Blood pressureBlood pressure

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Parent Vs. Nurse ReportParent Vs. Nurse Report

• Varying results in studies comparing Varying results in studies comparing parent, nurse, and self-reportparent, nurse, and self-report

• May be especially useful in cognitively May be especially useful in cognitively impaired childrenimpaired children

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Special SituationsSpecial Situations

• Cognitively impairedCognitively impaired

• Cerebral palsy with normal cognitive Cerebral palsy with normal cognitive levellevel

• Hearing or vision impairedHearing or vision impaired

• Non-English speakingNon-English speaking

• Intubated / paralyzed patientsIntubated / paralyzed patients

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Developmental FactorsDevelopmental Factors

• Newborns and small children unable to Newborns and small children unable to give self-reportgive self-report

• However, avoidance behavior has been However, avoidance behavior has been shown by at least 6 months of ageshown by at least 6 months of age

• Consistency of facial and cry response Consistency of facial and cry response has been shown in neonates and infantshas been shown in neonates and infants

• Children 3-5 yrs are able to use some Children 3-5 yrs are able to use some self-report measures, localize painself-report measures, localize pain

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Assessment in NeonatesAssessment in Neonates

• Neonatal Infant Pain Scale (NIPS)Neonatal Infant Pain Scale (NIPS)

• Objective Pain Scale (OPS)Objective Pain Scale (OPS)

• CriesCries

• Parent ReportParent Report

• Nurse ReportNurse Report

• Physiologic MeasuresPhysiologic Measures

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Neonatal Infant Pain ScaleNeonatal Infant Pain Scale (NIPS) (NIPS)

• Facial Expression - relaxed, grimaceFacial Expression - relaxed, grimace

• Cry - no cry, whimper, vigorousCry - no cry, whimper, vigorous

• Breathing patterns - relaxed, changedBreathing patterns - relaxed, changed

• Arms - relaxed, flexed/extendedArms - relaxed, flexed/extended

• Legs - relaxed, flexed/extendedLegs - relaxed, flexed/extended

• State of Arousal - sleeping/awake, fussyState of Arousal - sleeping/awake, fussy

Lawrence J, et. al

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Objective Pain Scale (OPS)Objective Pain Scale (OPS)

• Blood pressure - 10%, 10-20%, 20-Blood pressure - 10%, 10-20%, 20-30% preop30% preop

• Crying - not crying, crying +/- Crying - not crying, crying +/- response to TLCresponse to TLC

• Moving - none, restless, thrashingMoving - none, restless, thrashing

• Agitation - calm, mild, hystericalAgitation - calm, mild, hysterical

Broadman LH, Hannalah RS, et.al

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Objective Pain Scale (OPS)Objective Pain Scale (OPS)

• Verbal Eval / Body LanguageVerbal Eval / Body Language- asleep/states no pain- asleep/states no pain- mild pain (cannot localize)- mild pain (cannot localize)- moderate pain (localizes)- moderate pain (localizes)

Broadman LH, Hannalah RS, et.al

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Assessment in Infants and Assessment in Infants and Children < 3 YearsChildren < 3 Years

• OPSOPS

• CHEOPSCHEOPS

• Parent ReportParent Report

• Nurse ReportNurse Report

• Physiologic MeasuresPhysiologic Measures

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Children’s Hospital of Eastern Ontario Pain Scale Children’s Hospital of Eastern Ontario Pain Scale

(CHEOPS)(CHEOPS)

• CryCry - - None, Moaning, Crying, ScreamingNone, Moaning, Crying, Screaming

• FacialFacial - - Composed, Grimace, SmilingComposed, Grimace, Smiling

• VerbalVerbal - - None, Other, Pain, Both, PositiveNone, Other, Pain, Both, Positive

• TorsoTorso - - Neutral, Shifting, Tense, Shivering,Neutral, Shifting, Tense, Shivering,Upright, RestrainedUpright, Restrained

• TouchTouch - - None, Reach, Touch, Grab, RestrainedNone, Reach, Touch, Grab, Restrained

• LegsLegs - - Neutral, Squirming, Drawn-up, Standing, Neutral, Squirming, Drawn-up, Standing, RestrainedRestrained

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Assessment in Children 3-6 YrsAssessment in Children 3-6 Yrs

• Faces ScaleFaces Scale• Oucher ScaleOucher Scale• Poker Chip ToolPoker Chip Tool• Visual Analogue Scale (VAS)Visual Analogue Scale (VAS)• Observation ToolsObservation Tools• Parent ReportParent Report• Nurse ReportNurse Report

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

4 6 8 100 2

FACES Rating ScaleFACES Rating Scale

Adapted from Wong/Baker FACES Rating ScalesAdapted from Wong/Baker FACES Rating ScalesWong, D and Whaley, L: Clinical Handbook of Pediatric NursingWong, D and Whaley, L: Clinical Handbook of Pediatric Nursinged.2, p. 373, St. Louis, 1986, The C.V. Mosby Company.ed.2, p. 373, St. Louis, 1986, The C.V. Mosby Company.

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No Pain

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Numerical Rating ScaleNumerical Rating Scale

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Assessment in Children > 6-7 YrsAssessment in Children > 6-7 Yrs

• Self-ReportSelf-Report- VAS- VAS- Numerical Ranking Scale- Numerical Ranking Scale

• Observational ScalesObservational Scales

• Parent ReportParent Report

• Nurse ReportNurse Report

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

““Golden Rule” of Pain Golden Rule” of Pain AssessmentAssessment

• Don’t forget to ask the patient !!!Don’t forget to ask the patient !!!

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Pain Assessment in ChildrenPain Assessment in Children

““Pain is whatever the Pain is whatever the patient says it is.”patient says it is.”

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

• Infants do feel painInfants do feel pain

• Children do not tolerate pain better Children do not tolerate pain better than adultsthan adults

• Children can tell you where they hurtChildren can tell you where they hurt

• Children do not always tell The truth Children do not always tell The truth about painabout pain

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Facts About Children & PainFacts About Children & Pain

• Children do not become accustomed Children do not become accustomed to pain or painful proceduresto pain or painful procedures

• Behavioral manifestations of pain may Behavioral manifestations of pain may not reflect pain intensitynot reflect pain intensity

• Narcotics are no more dangerous for Narcotics are no more dangerous for children than adultschildren than adults

Pediatric Pain ManagementPediatric Pain Management P R O G R A MP R O G R A M

Facts About Children & PainFacts About Children & Pain

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